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Commonwealth of Massachusetts JI)f_fmial Useloyipfs
Permit No.: i
_ ;Iw''S' Department of Fire Services Occupancy and Fee Checked:
11__ BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/2023]
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 C 12.00
City or Town of: YARMOUTH_ Date: Y/3 ,R 1
To the Inspector of Wiles:By this application,the undersigned gives notices of his or her intention to perform the electrical work described below.
Location(Street&Number): h c ,,' Unit No.:
Owner or Tenant .3I'-r' )y o 1 o c a Email:
Owner's Address: Phone No.:
Is this permit in conjunction with a building permit?(Check appropriate box)Yes 0 WE Permit No.:
Purpose of Building: Utility Authorization No.:
Existing Service: Amps / Volts Overhead 0 Underground 0 No.of Meters:
New Service: Amps / Volts Overhead❑ Undergrounder 0 No.of Meters:
Description of Proposed Electrical Installation: IYi Sty)1 t f s, f r)( S evY,c ev me
LA- PU c L J e; 6-t c,..).-,ol
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-Gmd.❑ Above-Grnd.❑ Hot-Tub❑ 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 Supply Equi. .. C i D
No.of Modules: Roof-Mount 0 Ground-Mount ElLevel 1❑ Level 2 ElLevel 3■ i _ _ ___. -
OTHER:
1' ! 2n24
Attach additional detail if desired,or as required by the Inspector of Wires.15V
Estimated Value of Elecaic Work: kS e) (When required by "'_. "°,i rv�,NT
Date Work to Start:Cj f7 d 1 Inspections to be requested in accordance with MEC R " ',: d uputu um
FIRM NAME: A-1❑or C-I❑LIC.No.:
Master/Systems Licensee: 44 LIC.No.:
Journeyman Licensee: t I''C w O C.SZ fe t LIC.No.:a? 7 (0 Lr
Security System Business requires a Division/ of Occupational Licensure"S"LIC. S-LIC.No.:
Address: �L C.�'�- L C.i j c - (2 a
Email: iii y'-41e— S(j'n3 F-i ei, C'U,.•,Cc.5.fr.lve 1 Telephone No.: S66 S`k,O 6 C.51
I certi,under the pains and penalties of perjury,that the information on this application is true and complete.
. Licensee:'.../,11 4M WD1GS-re r Print Name: l/" Iiicw, CI CS-fh4 Cell.No.:SO S`C,a fe9)1
INSURANCE COVERAGE:Unless waived by the owner,no 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 same to the permit issuing office.
CHECK ONE: INSURANCE Er BOND 0 OTHER 0 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 0 Owner's agent 0
Owner/Agent: Tel.No.:
Signature: Email.:
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