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BLiiCommont�ealth'of Massachusetts Official Use Off.
= ey. Permit No.: Z✓?cc---C-3L
4! :' -Department of Fire Services Occupancy and Fee Checked:
1= 11 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 CMR 12.00
City or Town of: YARMOUTH Date: /—a S'-a 5--
To the Inspector of Wires:By this application,the undersigned gives notices of his or her intention to perform the electrical work described below.
• Location(Street&Number): 7> 9 C ci r-.(c,,,nil uili r-X Unit No.:
Owner or Tenant: /- to r o /L i un e 5 Email:
Owner's Address: litiv 7 ( (, v,-It fc;plc/ way ya✓ill, Phone No.: 5O j ?&O - O Y
Is this permit in conjunction with a building permit?(Checl(appropriate/ box)Yes❑ No['Permit No.:
Purpose of Building: l?esrrile„, �,c,( Utili Authorization No.:
Existing Service: .) c> Amps /is/.zcu Volts Overhead nderground❑ No.of Meters:
New Service: Amps / Volts Overhead❑ Underground❑ No.of Meters:
Description of Proposed Electrical Installation: r(; <;tn p 41 c Pt)„y f rP C,IaV iu
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❑ No.of Devices:
Swimming Pool:In-Grnd.❑ Above-Grnd.❑ 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❑ 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: /r vvio 1-I kl/l c �� /jec-ham/c,c h A-1 ❑or C-1 ❑LIC.No.:
Master/Systems Licensee: L •
LIC.No.:
Journeyman Licensee: r - vy C_-- LIC.No.: 6 2/• •.7 •
Security System Business requires a Division of Occupational Licensurc"S"LIC. S-LIC.No.:
Address: /?6. I c ,7 y�� % "/L74- , 1q C1,2.5--?‘
Email: -{-,.via hn<' 1 vt fy,� c2l yc;/ z, .C.c.-.- Telephone No.: Jay-f9.3E'63 Y
I certify,under pains and pen/ of perjury,that the information on this application is true and complete.
Licensee: /,c,J• Print Name: 71vNO--/-ir-/?�c_L:-r i - Cell.No.: 724/- .34 1/ .G
INSU CE COVERAGE:Unless waived by the owner,no permit fot'the performance ft5 electrical work may issue unless the licensee
. provi s proof of liability including"completed operation"coverage or its substantial equivalent.The undersigned certifies that such coverage
is in force and has exhibited proof of sam a permit issuing office.
CHECK ONE: INSURANCE OND❑ 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 0
Owner/Agent: Tel.No.:
Signature: Email.: