HomeMy WebLinkAboutBLDE-24-1250- Commonwealth of Massachusetts jfftgoipse( t_o
t - Permit No.: L
11 / Department of Fire Services Occupancy and Fee Checked:
BOARD OF FIRE PREVENTION REGULATIONS [Rev.I/2023]
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
City or Town of: YARMOUTH Date:
To the Inspector of Wires:By this application,the undersigned gives notices of his or her intention to perform the electrical work described below.
Location(Street&Number):,�C o 12,n Sr~zll r al Unit No.:
Owner or Tenant: /D pry /I!n t4 r 2 Email:
Owner's Address: 1 c2pf'; 5m21/ r Phone No.: cog 280-93 /S
Is this permit in conjunction with a building permit?(Check appropriate box)Yes I"No❑Permit No.: &D,X-o°v,32N
Purpose of Building: Utility Authorization No.:
Existing Service: Amps / Volts Overhead❑ Underground❑ No.of Meters:
New Service: Amps / Volts Overhead❑ Underground❑ No.of Meters:
. Description of Proposed Electrical Installation: yeo 101,
Completion of the following table may be waived by the Inspector of Wires.
No.of Receptable Outlets: No.of Switches: Generator KW Rating: Type:
No.Luminaires: No.of Recessed Luminaires: No.Wind Generators: Wind KW Rating:
No.Appliances: KW: No.Water Heaters: KW: No.Transformers: Total KVA:
Space Heating KW: Heating Equipment KW: No.Motors: Total HP: Total KW:
No.Heat Pumps: Total KW: Total Tons: Fire Alarm System❑ No.of Devices:
Swimming Pool:In-Grad.0 Above-Grad.0 Hot-Tub 0 No.of Self-Contained Detection/Alerting Devices:
No.Oil Burners: No.Gas Burners: Video System 0 No.of Devices:
No.Air Conditioners: Total Tons: Telecom System 0 No.of Outlets:
No.Energy Storage Systems: KWH Storage Rating: Security System 0 No.of Devices:
Solar PV KW DC Rating: Solar PV KW AC Rating: No.of Electric Vehicle r D
No.of Modules: Roof-Mount 0 Ground-Mount 0 Level 1 0 Level 2❑ L 1 ""n�.
OTHER:
AUG-1 212
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When re IttilledbymfeitkiOnicifib i
Date Work to Start: Inspections to be requested in accordance with A -R. 10,and upon..on pletion.
FIRM NAME: A-1 0 or C-1 0 LIC.No.:
Master/Systems Licensee: LIC.No.:
Journeyman Licensee: LIC.No.:
Security System Business requires a Division of Occupatipnal Licensure"S"LIC. S-LIC.No.:
Address: /
Email:4N/O NO H/(4 tf R 0/r,7a f. c 9 Telephone No.:C0 8 2o
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
LigtOstrsr Print Name: /D'7 Az,/i r a Cell.No.:
INSURANCE C VE GE:Unless waived by the owner,no permit or the performance of electrical work may issue unless the licensee
provides proof of liability 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:
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)Owner❑ Owner's agent❑
Owner/Agent: Tel.No.:
Signature: Email.:
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