HomeMy WebLinkAboutBLDE-24-1037 RECEIVED
�A. Commonwealth��Ia�,a�l dial Use Only
'r JU': a 4 tea ..ServicedPermit No.l 2-.14--L f'J 57
BUILDIN * n MENT Occupancy and Fee Checked
By_-_-- _' - --:a_RD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perforated in accordance with the Massachusetts Electrical Code(MEC),527 Chill.12.00
(PLEASE PRINT IN INK OR�T�PE ALL INFORMATION) Date: ry/4 P/,.a '
$ City or Town of:Iyi9C.%'c 7 To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Ul Location(Street&Number) g' /�t/i..G/i�S�c{i,_ C
\, Owner or Tenant PM,/ to t cs.P/.e J�/921 s Telephone No.job->vi-?`Sy
�^ Owner's Address .tm.t-eA.
-�-
Is this permit in conjunction with a building/pe,r�mk?ca Yes ICJ No El (Check Appropriate Box)
F�o. i�t'Purpose of Building , .' c, ,relic ry 4137 Utility Authorization No.
Existing Service Amps / Volts Overhead El Undgrd El No.of Meters
New Service Amps / Volts Overhead❑ Undgrd El No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
••
Completion of the following table may be waived by the inspector of Wires.
Li/ No.of Recessed Luminaires No.of CeLL (Paddle)Fans No.of Total
��• Transformers KVA
Q No.of Lumhulre Outlets No.No.of Hot Tubs GeneratorsKVA
Above In- No.of Emergency Lighting
-t No.of Luminaires Swimming Pool trod. ❑grnd. ❑ Battery Units
J No.of Receptacle Outlet No.MOH Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burner rNo of Inht tngon and
i atln4 Devices
No.of Ranges No.of Air Cond. Tan' No.of Alerting Devices
No.of Waste Disposers 'Beat Pump Number Tons._. KW No.of Self-Contained
Totals: Detection/Alertins Devices
No.of Dishwashers Space/Area Heating KW Local 0 laT k3nectl e 0 OtherNo.of Dryers Heating Appliances KW SecNa o y f Systems:"
s or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW Signs Ballasts No.of Devices or Equivalent
No.H dro a Bathtubs No.of Motors Total HP Telewmmunk;ations Wiring:
Y m�a8 No.of Devices or Equivalent
OTHER:
Attach additional detail if desired.or as required by the Inspector of Wires.
Estimated Value of Electrical Work: '/SoC,' (When required by municipal policy.)
Work to Start: j/ 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 0 OTHER 0(Specify:)
I certify,under the pains and penalties ofper}ar,,that the information on this application is true and complete.
FIRM NAME: LIC.NO.:
Licensee: Signature LIC.NO.:
(if applicable,enter"exempt"in the license number line.) Bus.Tel.No:
Address: 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 ins ce coverage normally
required by law. By my signature below,I hereby waive this requirement. l am the(check one)[owner 0 owner's agent.
OwrAgent
Signaneture � �,-_/ Telephone No. ciii^c7rI-6aY1' PERMIT FEE:$