HomeMy WebLinkAboutBLDE-20-4029 RECEIVED
' JAN 22 "� 1
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t3U Ic DINti Ur riaLNT l,ommonwaa(lh of'r/aeeaeiitwtie �tN�fiJci�a�l Usej O�ply •
as _— ' t=. cc77�, ec�t ((� Permit No.(./ LO f D 1.1
;j'W�. 2�ni of Jirr Jervicee
1.I,t Occupancy and Fee Checked
^r BOARD OF FIRE PREVENTION REGULATIONS [Rev,107] (leave bunk)
t(`�11/�1 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 •
,dy (PLEASE PRINT IN INK OR TYPE ALL LVFORMATIOM Date: //7 7/z e z o
�(Y City or Town of: YARMOUTH To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work descn& ,C - q C .O
Location(Street Number) . rU,f /LJOChs ....Si.jf, (A), y0.mr O
Owner or Tenant /.ft r k /C1/O t r, Telephone No. k
Owner's Address /7/ y"x,;/-pc, /1t/� tom,r� SesN 1Is this permit in conjunction with a/buildinng'permit? Yes No (Cheek Appropriate Box)
JPurpose of Building Utility thorizatton No.
0 Existing Service/00 Amps /70/2(fV Volts Overhead Undgrd❑ No.of Meters /
yew Service _ Amps / Volts Overhead❑ Undgrd❑ No.of Meters _
Number of Feeders and Ampacity /
Location and Nature of Proposed Electrical Work: P /
.,.,-
Completion of the/o(lowin !allo. rble may be waived be the/nspecror of Wires.
No.of Recessed Luminaires No.of CeiL-Sosp.(Paddle)Fans Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
�i
' ' ..r No.of Luminaires Swimming Pool Abovd. crud. Bae 0 In- ❑ No.tt ofery U Emnitsergency Lighting
gra
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
7 No.of Switches No.of Gas BurnersNa.of Detection and—
initiating Devices
t,•' No.of Ranges No.of Air Cond. Too Total No.of Alerting Devices
•
No.of Waste Disposers Heat Pump Number-Tons KW 'No.of Self-Contained
Totals: Detection/AlertIng Devices
No.of Dishwashers Space/Area Heating KW Local Q Co nnnee,.don O Other
Co
No.of Dryers Heating Appliances ICW Security Systems:.
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters•
Signs Ballasts No.of Devices or Equivalent •
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications W irin :
No.of Devices or Equivalent
OTHER:
•
Attach additional detail if desired or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent The
undersigned certifies that such cov9giis in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE:INSURANCE BOND❑ OTHER 0(Specify:)
I certify,under the pains and penalties of pe'ury,that the information on this application is true and complete.
FI' Rbt NAME: '�,.? 6�`=2e.r l r-/ rr,)r•es LIC.NO.: F/y8 p,3
Licensee: i� (u) �Z.r Signature y C,j1�LIC.NO,:_f/r//83?
1 r
(If applicable,enter"exempt'in the license number line.) us.Address: p0 ,Tj,yr c� [t i,1Ce /�5h (1?h 3/ IL Tel.No.SOH saj6.S2/7 •
•Per M.G.L.c.147,s.57-61,securi work AIC Tel.
security requires Department of Public Safety"S"License: Lic.Nao.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner Q owner's agent.
Owner/Agent
Signature Telephone No. I PERMIT FEE:$ ,c0 "I"—