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6BUILDING DEPARTMENT jci,
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i�__ ff Permit No.: 'C�7,�f`i
;': -..1�l;�`5 Department of Fire Services Occupancy and Fee Checked:
'-1.1 " 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 MR 0
City or Town of: YARMOUTH ' • Date:
To the Inspector of Wires:By this a pli ' i,the undersigned iv '�otticcs of hi r her into io to perform the c1cctri I wor escribed low.
• Location(Street& umbe): e e c,o �( ' Unit No.:
Owner or Tenant: J !I U 4 Email:
Owner's Address: . e Phone No.:
Is this permit in conjun n with building permit?(Check appropriate box)Yes No❑Permit No.:
Purpose of Building: f� 114 Utili Authorization No.:
Existing Service: Am6 / Volts Overhead 0 Underground❑ No. of Meters:
New Service: Amps / Volts Overhead❑ U derground❑ o. of Meters:
Descript" of Pro osed Electrical Installation: ��/f ed 7 %v/� 1Pg f(/'C77 rt'
Iq7�I too J/9
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 0 No.of Devices:
Swimming Pool:In-Grnd.❑ Above-Grnd.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 ❑ 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❑ 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 Elect' I Wo k: (When required by municipal policy)
/Date Work to Start: / 27 r. Inspections to be requested in accordance with MEC Rule 10,and upon completion.
• FIRM NAME: A-1 ❑or C-1 ❑LIC.No.:
Master/Systems Licensee: LIC.No.:
�
Journeyman Licensee: FJ 1 L-- ., C 7 LIC.No.:7 c 6O / f:
Security System Business r ires a Division of Occupational Licensure" "LIC. S-LIC.No.:
Address: r
Email: G Telephone No.: 7 Y� �9 g
I certify,un er se pant enaltles perjury,that the rmation of t)( (
' applicati t is true and complete./�
Licensee: Print Name: �� Cell.No.:77"I -? - /Ig
INSURA E COVE AGE: nless waived by the owner,no permit for the perfornhnce of el trical work may issue unless the licensee
provides proof of liability includi "completed operation"coverage or its substantial equivalent.The undersigned certifies that such coverage
is in force and has exhibited proof•f .me to the permit issuing office.
CHECK ONE: INSURANCE 1 BOND 0 OTHER❑ Specify:
OWNER'S INSURANCE AIVER: 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.: