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BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] Leave bl. kn�%
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APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1 2/ 1 5 /2 0 2 1
City or Town of: Yarmouth To the Inspector of Wires:
By this application the undersigned gives notice of his or her in nti• I . rform the electrical work described below.
Location(Street&Number) 2 4 Orchid Ln
Owner or Tenant Mildred Cleary Telephone No. 7 8 1 -5 9 2-7 7 7 9
Owner's Address 2 4 Orchid L n
Is this permit in conjunction with a building permit? Yes o ril. (Check Appropriate Box)
Purpose of Building Residential ..r. . t o No. l ii 9 9 7 7 1
Existing Service 1 0 0 Amps 1 1 0 I 420 Volts Ove t dES //� No.of Meters 1
New Service 200 Amps 1 1 0 / 220 Volts Ove , :: . r� :t No.of Meters 1
Number of Feeders and Ampacity O
Location and Nature of Proposed Electrical Work: Replacement of Federal Pacific fuse panel with new 30 ckt panel.Outlet by panel.Light
by panel.Grounding rods.Meterbank disconnect. Upgrade to 200 Amp service.
Completion of-the followingtahle may he waived by the Inspector of Wires.
No.of Recessed Luminaires No.ofCeil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting
grad. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices •
No.of Ranges No.of Air Cond. Total No.of AlertingDevices
Tons
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❑ Municipal
Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KWNo.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Q 1010-00 Attach additional detail ifdesired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 1/5/2022 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 coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: K Security Systems LIC.NO.:
Licensee: James R K e i g h l e y Signature 2 l6. LIC.NO.: 15741A
(If applicable,enter "exempt"in the license number line.) Bus.Tel.No.: 781-592-7779
Address 543 Boston St, Lynn, MA 01905 Alt.Tel.No.
*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
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 ❑owner's agent.
Owner/Agent I PERMIT FEE:$
Signature Telephone No.