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Commonwealth of Massachusetts Official Use On
Permit No.: 7S-f—1'(LA
r ii__ Department of Fire Services Occupancy and Fee Checked:
1 -" BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/2o23)
°•-�'` 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: 1)- 12-2-t1
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(t�aS,c �a,i1,P '+\I ) Unit No.: /�
Owner or Tenant: L4�,ll l (.8YlU1 — 1Ai1)'LL L Email: l eb i le . cb ($
Owner's Address: 6O.('7!Q_ Phone
Is this permit in conjunction with a building permit?(Check appropriate box)Yes 0 No 0 Permit No.:
Purpose of Building: Utility Authorization No.:
Existing Service: Amps / Volts Overhead❑ Underground 0 No.of Meters:
New Service: Amps / Volts Overhead❑ Underground ElNo.of Meters:
Description of Proposed Electrical Installation: 1 Y1 S4.`tin l 1 Ye C Pssk_d ikl 1t9
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.0 Above-Gmd.❑ 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❑ No.of Outlets:
No.Energy Storage Systems: KWH Storage Rating: Security System ❑ No.of Devjo..
Solar PV KW DC Rating: Solar PV KW AC Rating: No.of Electric Vehicle Supply Eq ip n C E I _ . __
No.of Modules: Roof-Mount 0 Ground-Mount 0 Level 1 El Level 2 0 Level 3 g:--- - .__
OTHER: r
tiOV 12. 2024
Attach additional detail if desired,or as required by the Inspector of Wires. 5 U i D iry- �ART ME N T
Estimated Value of Electrical Work: (When required by rcipal_psIlicy)-_— _—
Date Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
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 Occupational Licensure"S"LIC. S-LIC.No.:
Address:
Email: Telephone No.:
I certify,u 1 he pains a enalties of perjury,that the in ormation on this a ication is/true and complete. p p
L oan oe>� ' Print Name: �1 �!yew No.: 7714�% I LI=LLI1#
INSURA CE COVERA : Unless wa' ed by the owner,no permit for the performance of electrical ork may issue unless the licensee
provides proof of liability including"completed operation"coverage or its substantial equivalent.The u signed 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.: