HomeMy WebLinkAboutBLDE-24-1639 Commonwealth of Massachusetts Official Use ply
' __ Permit No.: SjZ1—t—Ptp3-1
Y . Department of Fire Services Occupancy and Fee Checked:
e'- Rev.I/20231
1,_ ' BOARD OF FIRE PREVENTION REGULATIONS i
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 27 MR 14AO(74
City or Town of: YARMOUTH Date: /0 (` '/
To the Inspector of Wires:By rs p rcati e uetagned$jv tires his or her intention to perform the electricallwork de cubed below.
Location(Street&Number): O UU(( l' /7C ///MG3 Unit No.:
Owner or Tenant: /jf/'r 5 1..1'/./,YA 1-t! G Email:
Owner's Address: // Phone No.:
Is this permit in conjunction with a building permit?(Check appropriate box)Yes No 0 Permit No.:
Purpose of Building: Utility Authorization No.:
Existing Service: Amps / Volts Overhead❑ Underground❑ No.of Meters:
New Service: Amps / Volts Overhead❑ Underground 0 No.of Meters:
Description of,Proposed Elecyyical Installation: f/tg it CP I P
5r�'i'�ke. fiilie/Q 4e P . �r�ja f 6/i /// '.
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: Total KW: Total Tons: Fire Alarm System 0 No.of Devices:
Swimming Pool:In-Gmd.0 Above-Gmd.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 Supply Equipment:
No.of Modules: Roof-Mount 0 Ground-Mount 0 Level I 0 Level 2 0 Level 3 0 Rating:
OTHER: -7 1,� �
Attach additional detail if desired,or as equired by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy)
Date Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
FIRM NAME: A-1❑or C-1 0 LIC.No.:
Master/Systems Licensee: LIC.No.:
Journeyman Licensee: Iti(ei.,Ti/d (�,,/,'/ LIC.No.:3 4 c 7,
Security Systemte Business requires a Division of /ccupational Licensure"S"L C. yJ S-LIC.No.:
Address: -•c�1/jIC/ 0 (/IQ• ✓l/• Cr//f7/Di/7'�/i(�i5,
Email: p �(� �(� q /G/OCJCi, Telephone No.: 7,Cf 79'
I certi un the pain a penalti f perjury,that the in or ation on t is applic Hon is true and co iete.
Licensee:�///,('� 1i, Print Name: be/t9/(1.
/J
/forthC7 fir//( Cell.No. t/ '�1I;
INSURANCE COVERA E•nless waived by the owner, permit for the perfor(nance of electrical work may issue unless the licensee
provides proof of liability induct'g completed operation"coverage or its substantial equivalent.The undersigned certifies that such coverage
is in force and has exhibited proof of se to the permit issuing office.
CHECK ONE: INSURANCE OND 0 OTHER ElSpecify:
OWNER'S INSURANCE W IVER: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❑
Owner/Agent: Tel.No.:
Signature: Email.: