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Ins peiecil
SI,\ Official Use Only
Commonwealth of Massachusetts _ f
Mi_i_:it- et 1 Permit No. Z-'' `
>el_ - Department of Fire Services '
C^--- BOARD OF FIRE PREVENTION REGULATIONS I Occupancy and Fee Checked _________•
l[Rev.9/US] (leave blank) _;
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Dr 31 Zv 2Y _ ___
City or Town of: YAR_PlDi,r?-{�' — _ _ To the Inspector1of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) ,j (y-/0M.;,./o C-'> Sii"2 cr Ct/, y/I'rpp ,,-//
Owner or Tenant P.cT- c" RO/Li vJt— .K row Telephone No, —
Owner's Address
Is this permit in conjunction with a building permit? Yes ri No ICJ (Check Appropriate Box)
Purpose of Building ))w(((;f..) (,- Utility Authorization No._`_
Existing Service Amps / Volts Overhead I I Undgrd U No.of Meters
New Service Amps / Volts Overhead Li Undgrd No.of Meters
Number of Feeders and Ampacity —
Location and Nature of Proposed Electrical Work: I/V c,7(j fit k) F`,q 6.,po(.e t.,?"S Lvi'ti Mt:,ec)
__ Completion of the following table may he waived by the Inspector of Wires.
Total
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Tf
Trr Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting
grnd. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices
t Heat Pump Number I Tons i KW No.of Self-Contained
No.of Waste Disposers Totals:1 1 1 Detection/Alerting Devices
Municipal
No.of Dishwashers Space/Area Heating KW Local❑ Connection U Other
No.of Dryers Heating Appliances KW Security Systems:*
_No.of Devices or Equivalent
_
No.of Water KW No.of —1 i.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule l0,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and ta_s exhibited proof of same to the permit issuing office. _.
CHECK ONE: INSURANCE X❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjurii,that the information on this application is true and complete.
FIRM NAME:BJA`/5.0t, EJrCT(, (fit (Jct?rv_Citi S 7,,, i NO.:�j /✓ `
Licensee: TJi jf& r L,a hi ri-,( f Signatu M,, . s y ,; •' .NO.:��
(If applicable,enter"exempt"in tie licer se number line.) ' M '+o BuS. 1'el.No.:
Address:S.7 ri D`T« 1-1 i)r U1. y>iRi L)L), II Al U2_(,' } Alt.Tel.No.:J11fY/' 2,4- iUO , 7*Security System Contractor License required for;this1work;if applicable,enter the license number here:
OWNER'S INSURANCE WAIVER: I am awafe 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.
Ow
gRteture Telephone No. PERMIT FEE: $ 1
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R I N1ENT
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