HomeMy WebLinkAboutBLDE-24-1782 Commonwealth of Massachusetts Official Use Only, \Z
tt " Permit No.: � {— ( ' [ L-�
_aiil;� ' Department of Fire Services Occupancy and Fee Checked:
=•W �g.- I BOARD OF FIRE PREVENTION REGULATIONS [Rev I/2023] •
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W RK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 5 7 R 1 .
City or Town of: YARMOUTH . Date:
To the Inspector of Wires:By this app' ion,th undcrs' ed a es ccs of his or h r intention to perform the electricalfork des ribed bet w.
• Location(Street&Number):a (( �e4 v e 7/ 0 Unit No.:
Owner or Tenant: ''"/ ed--t Email)...
Owner's Address: �.4 . . - Phone No.:
Is this permit in conjunction il51ip permit?(Check appropriate box)Yes No 0 Permit No.:
Purpose of Building: Utili Authorization No.:
Existing Service: Amps r Volts Overhead❑ Underground❑ No.of Meters:
. New Service: Amps / Volts Overhea fti7
rground❑ No. ters:
. Description of Prop° ed Electricyrm
/j/',e �t t / t •/9
Fq4 g A PCe/ e c., t
Completion of the followingtable maybe waived bythe Inspector ofWires. .
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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-Grnd.❑ Above-Grnd.0 Hot-Tub 0 No.of Self-Contained Detection/Alerting Devices:
No.Oil Burners: No.Gas Burners: Video System ❑ No.of Devices:
No.Air Conditioners: Total Tons: Telecom System❑ 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 ❑ 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 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 0 or C-1 ❑LIC.No.:
Master/Systems Licensee: LIC.No.:
Journeyman Licensee: Eci ti / (/-le4C>4 LIC.No.: 35 6eYrF
Security System Business req 'res a Divisio of Ocpational Liccnsure"S"LIC. S-LIC.No.:
Address: �7 t/t 9 foal `.t'/ P' l4lardp",,,e7r54(v 0-3Email: f//f�v ('//f 4 G f �--f' ,(fg Telephone No.: 77q—^ --0?3,91
I certify,and I pains and Ides of erjury,that the it h ation on th' plication is true and com fete.
Licensee: P ' t Name: L �C Cell.No.:/,�v� — 97�
INSURA VERAG . ss wa ed by the owner,no ermit for the performanceof electrical work may issue unless the licensee
provides proof of liability including' ompleted operation"coverage or its substantial equivalent.The undersigned certifies that such coverage
is in force and has exhibited proof s me to the permit issuing office.
CHECK ONE: INSURANCE .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.: