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_ Commonwealth of Massachusetts e;fal Use oq]y_
Permit No.: q_i z5�`ci
11 i Department of Fire Services Occupancy and Fee Checked:
—In Li ' BOARD OF FIRE PREVENTION REGULATIONS lRev.1/2023]
,
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 27 CMR 12.00
City or Town of: YARMOUTH_ Date: �i (y 2e,a
To the Inspector of Wires:By this application,th dersigned notices of his or her i ention to perform the electrical work described below.
Location(Street&Number): /[/c'f/It [�[,n�,5 ,) Unit No.:
Owner or Tenant: /eyc,1 c,n,.r (, Email:
Owner's Address: Phone No.:
Is this permit in conjunctio with a building permit?(Check appropriate box)Yes❑ No❑Permit No.:
Purpose of Building: ,CLvt kzit Utility Authorization No.:
Existing Service: 'cc,) Amps /Zc/r(t'/Volts Overhead 0 Underground a No.of Meters:
New Service: Amps / Volts Overhead❑ Underground❑ No.of Meters:
Description of Proposed Electrical Insta Iation: ,, ft u n/� Rx�( 3$ ct5 ec c, d Pau,
f 5 h Povu-(Coif 1 Z/P 4 S i �r:�fca/Covert T Lv %S4 Co f5 I s L�afr! 3
l� Completion of the following table may be waived by the Inspector of Wires.
No.of Acceptable 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: Tott,,,a___ll KW: Total Tons: Fire Alarm System 0 No.of Devices:
Swimming Pool:In-Gmd.�p Above-Gmd.El Hot-TubEl No.of Self-Contained Detection/Alerting Devices:
No.Oil Bumers: ` No.Gas Burners: Video System ❑ No.of Devices:
No.Air Conditioners: Total Tons: Telecom System 0 No.of Ottlffi.
0 C I V r
No.Energy Storage Systems: KWH Storage Rating: Security System El No.of Di v : — __ _4/
Solar PV KW DC Rating: Solar PV KW AC Rating: No.of Electric Vehicle Supply Equipment: D )l
No.of Modules: Roof-Mount El 0 Level 1 0 Level 2 El Level 3❑ AUGRati g: 1 O it
OTHER: /tU
/Sd F
---- ----- .RTMNT
Attach additional detail if desired,or as required by the Inspector of Wires. _Sc --
Estimated V�ue,o�fE)ectrical Work: !?/000. o c> (When required by municipal policy)
Date Work to StSrtr ei y�- Inspections to be requested in accordance with MEC Rule 10,and upon completion.
FIRM NAME: �Y/,,,fr 2 Am i f 4,11/.cam A-I 0 or C-1❑LIC.No.:
Master/Systems Lice t1 see: T LIC.No.: *--
. Journeyman Licensee: es 2...f l�a,n ,7 LIC.No.: v ----.3A'2 5
Security System Busines` auiress a Division of Occupational Licensure"S"LIC. S-LIC.No.:
Address: t� / /c,<./cvS C//. � ly—co" pis#4,Tor."'g'
EmaiLeLe.. f -1,'e G1 aac../l . C.,--., - Telephone No.:7' '7 9 loye..._
I certify and r the pains andsue .nalties of perjury,that the information on this a plicatio • true and complete.
Licensee: /- w [�/ . Print Nam*�T Cell.No.:
INSURANC 'COVERAGE:UnlessUnlesTaived by the aasi to permit for 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 a to the permit issuing office.
CHECK ONE: INSURANCE BOND 0 OTHER 0 Specify:
OWNER'S INSURANCE W I ER: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 0
Owner/Agent: Tel.No.:
Signature: Email.: