HomeMy WebLinkAboutBLDE-24-1620 Commonwealth of Massachusetts Official Use
bnL CJ Permit No.:
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10,-, Department of Fire Services Occupancy and Fee Checked:
• al li-s1, 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 CMR 12.00
City or Town of: YARMOUTH Date:
To the Inspector of Wires:By this ap ii lion,the undersi ed gives notices of his or her intention to perform the electrical work described below.
Location(Street&N ber): Unit No.:
Owner or Tenant: c4c e s J \ it Email:
Owner's Address: () ) �ryc\p - Phone No.:
Is this permit in conjunction with a building permit?(Check appropriate box)Yes(p No 0 Permit No.:
Purpose of Building: t\r �\c m\\ Utility Authorization No.:
Existing Service: Amps /3 Volts Overhead❑ Underground 0 No.of Meters:
New Service: Amps / Volts \O( l\ \\
erhead U ouu�n-d❑ No. f Meters:_
Description of Proposed Electrical Installation: —ki Q V � Ad\\ \Flit Cti`no, uCt,'CO,.
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: OCT 1 O 2024
No.Heat Pumps: Total KW: Total Tons: Fire Alarm System 0 No.of Devices; V
Swimming Pool:In-Gmd.❑ Above-Gmd.❑ 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 Supply Equipment:
No.of Modules: Roof-Mount 0 Ground-Mount 0 Level 1 0 Level 2 0 Level 3 0 Rating:
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical ork: O(L (When required by municipal policy)
Date Work to Start: ry Ins ections to be requested in accordance with MEC Rule 10,and upon completion.
FIRM NAME: `VQ{ ,bcA q.CstQ an CAN\ A-1❑or C-1 0 LIC.No.:
Master/Systems Licensee: LIC.No.:
�a�{5 Journeyman Licensee: , ?,ky 0,1\64-42'1 LIC.No.: CII l{(F-
Security System Business req ires a Division of Occupational� Licensure"S"LIC. S-LIC.No.:
Address: .7 3\511)Q.W'SD•J i"-c 1 \�C)l« �l�Ej� ' SO
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Email: G.\\C��{\Q'(�(.)�� O�Qr$�T.\\a L,O(�(\ TelephoneNo.: `lOb (,,It(Pan
I certify,and the Q ° /(3tPrintName:
n i ofperju y,that the in ormtlion on this p l ca ion is true and complete.Q t�
Licensee: ('L1/p5 f, //a jn'c( Cell.No.:INSURAN COAGE: les aived by the owner,no permit for the performance odelectrical 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 El ❑ Specify:
OWNER'S INSURANCE WAI 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❑
Owner/Agent: Tel.No.:
Signature: Email.: