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_ -� Commonwealth of Massachusetts Official Use Only_
i•. Department of Fire Services Occupancy and Fee Checked:
`- '�'A " BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/2023] • ( ✓
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in aceordancewith the Massachusetts Electrical Code(MEC), 527 CMR 12.00
City or Town of: YARMOUTH Date: mil/.' 7, t2002if
To the Inspector of Wires: By tth,g application,the undersigred gives y
ces of his or her intctp to perform the electrical work described below.
Location(Street&Number): U lit 11[jOA`AO U-E C ‘ Unit No.:
Owner or Tenant: LAlJri'tifl C 2., 7f ;4L5 Email:
Owner's Address: Phone No.:
Is this permit in conjunction with a buildin pe tt?(Check appropriate box)Yes IN No❑ Permit No.:
Purpose of Building:On 1, 1141.`fly- 14) ltn Utility Authorization No.:
Existing Service: /DO Amps ItUl /6?-0olts Overheat Underground❑ No.of Meters: 1
New Service: Amps / Volts Overhead❑ Underground 0 n No.of Meters:
t
Description of Proposed Electrical Installation: )r T t�� Oc �'}PFihd [2 l�}rt.
Completion of the following table may be waived by the Inspector of Wires.
No.of Receptable Outlets: No.of Switches: 2 Generator KW Rating: Type:
No.Luminaires: g 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.0 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 0 Ground-Mount❑ Level I ❑ Level 2 0 Level 3❑ Rating:
OTHER:
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Attach additional detail if desired,or as equired by the Inspector of Wires. ____�..__
Estimated Value of Electrical Work: 0A2O,00 (When required by municipal policy) •
Date Work to Start: I(-6— at 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 t I U s`k y LIC.No.:3 c$� /-;.,'
Security System Business requires ag Division fof Occupationalt Liccnsurc"S"LIC. S-LIC.No.:
Address: ai.t'�. ( tP L 1-isc (oi(ii '('r I,�. / /
Email: rib)'t I k5: �4C t 1 . in Telephone No.: - /�—�(p3(Q
I certify,u the p is a enallWf perjury,that the in orurati a on this licalion is true and complete.
Licensee Print Name: )/ QI( I 0 I 1 Cell.No.:401 3,4o-243p
INSURANCE VERAG .Unless waived by the owner,no permit for the performance electrical work may issue unless the licensee
. provides proof of liability• uding"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.: