HomeMy WebLinkAboutBLDE-24-1738 Commonwealth of Massachusetts o .i.ciail.ke o773fr
�r _; = Permit No.: L �
_.,.liU :' Department of Fire Services Occupancy and Fee Chccke :
e 'I 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 0
City or Town of: YARMOUTH . • Date: AbtX 7l t°�y
To the Inspector of Wires:By this applica^tioR,th undersigned ivcs n ' es of his or l cr' t tion to perform the electrical work described below.
• Location(Street&N m ): ,/�r -f t t Unit No.:
Owner or Tenant:ts(11.7 t E115 R Email:
Owner's Address: Phone No.:
Is this permit in conjunction fith a b ildin ermit Check appropriate box)Yes in No❑Permit No.:
Purpose of Building( r1,1 I f L) 41t n Utility Authorization No.:
Existing Service: /09 Amps/ D Volts Overhead in Underground❑ No.of Meters: 1
New Service: Amps / Volts Ove ead❑ Underground❑ No.of Meters:
Description of Proposed Electrical Installatio : S4. D Yet, 'rfhT00114- t
Completion of the following table may be waived by the Inspector of Wires. .
No.of Receptable Outlets: 1 No.of Switches: 02, 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-Grnd.❑ Above-Grnd.❑ 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❑ No.of Outlets:
No.Energy Storage Systems: KWH Storage Rating: Security System ❑ No.of Devices:
Solar PV KW DC Rating: Solar PV KW AC Rating: No.of Electric Vehicle Supply Equipment:
No.of Modules: Roof-Mount❑ Ground-Mount❑ Level 1 0 Level 2 0 Level 3 0 Rating:
OTHER:
Attach additional detail if desired,or a required by the Inspector of Wires.
Estimated Value of Electrical Work: �(r 2•e (When required by municipal policy) •
Date Work to Start: 7 (9 Inspections to be requested in accordance with MEC Rule 10,and upon completion,
FIRM NAME: A-I 0 or C-1 ❑LIC.No.:
Master/Systems Licensee: LIC.No.:Journeyman Licensee [AO.1\\'‘)i LIC.No.: a 7 , /��E
Security S stem Business requires a Division of Occupation I Licensure"S"LIC. S-LIC.No,:
v
Address: ) V
Email: l . Telephone No.: 3 _ - q
I certify, the i s a enalti of perjury,that the infornnati a on this plication is true and complete.
t
Licensee. 1 Print Name .fit 11_ Lt) 1 1 Cell.No.:WO"434
INSURANCE C RA : 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 ►'. 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.: