HomeMy WebLinkAboutBLDE-25-41 Commonwealth of Massachusetts Official use Only /
_..___,__ Permit No.: �5-� /
___ s,__., Department of Fire Services Occupancy and Fee Checked: `
e 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), 52'j.CMR 12.00
City or Town of: YARMOUTH Date: /i`f ? j
To the Inspector of Wires:By this appl' `tion,the unders'gned gives notices of his or�, /herintention to perform the electrical Iork described below.
Location(Street&Number): t? if&C(�, T C-&Ve GI J (mil e Unit No.:
Owner or Tenant: ,)Q� Q//i!7 &. ` Email:
Owner's Address: Phone No.:
Is this permit in conjunctioA with a b ilding permit?(Check appropriate box)Yes, No El Permit No.:
Purpose of Building: ate//I 1 J Utility Authorization No.:
Existing Service: A ps J / Volts Overhead❑ Underground❑ No.of Meters:
New Service: Amps / Volts Overhead❑ Under round El No.of Meters:
Description of Proposed Electrical Install Lion: 4 ' &V ,/Cf( . ,e(r?0'7
1 e/ / ' lib Y e('' tr/1 L
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.❑ Hot-Tub❑ 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 I
No.Energy Storage Systems: KWH Storage Rating: Security System El No.of Device':R_E C I V C
Solar PV KW DC Rating: Solar PV KW AC Rating: No.of Electric Vehicle Supply Equipment: 1'
No.of Modules: Roof-Mount El Ground-Mount0 Level 1 ElLevel 2 ElLevel 3 ElRating: JAN 0 8-/(1/5
OTHER: { 4` .s,. _ )
- 1- 13-1-1 C D E I.'1 RTAlI E NT
Attach additional detail if desired,or as required by the Inspector of Wires. By — —
Estimated Value of Elec pi al ork: (When required by municipal policy)
Date Work to Start: I 7 , Inspections to be requested in accordance with MEC Rule 10,and upon completion.
FIRM NAME: 0 or A-1 ❑LIC.No.:
C-1
Master/Systems Licensee: I LIC.No.:
Journeyman Licensee: F4,17,./ ..( /l(, /7- LIC.No.: J 7 Il�1�
Security System Business requires a Divisio of Occupational Lice sure"S"LIC. S-LIC.No.:
Address: w j / X r L 11 i/ r I
Email: ' '. 7/t//W O 0 "j"at Telephone No.:. 7 I'
I certify,and /he pains; enalties`tperjury,that the infor ation on tC /l
' applicati n is true and complete.
Licensee. 1/Wo' ,( , •rint Name: -r-,d24 e, Cell.No.: 7 7 � .�(���ty
(�
75 b
INSURANCE COVERA : nless waived by the owner,no permit for the performlutce of electrical work may issue unless the licensee
provides proof of liability includin "completed operation"coverage or its substantial equivalent.The undersigned certifies that such coverage
is in force and has exhibited proof of s e to the permit issuing office.
CHECK ONE: INSURANCE BOND El OTHER El Specify:
OWNER'S INSURANCE W(IVER: 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.: