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CommonwfaUh o/f7ta4SacLisiif Official Use Only ?�
".y, t ' cc�'�/� t n Permit No. ��
21 epartinant O f�iro Se vC/a
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1:'07j (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
Ali work to be performed in accordance with the Massachusetts Electrical Code(MEC),52'CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: a -5-0 j
City or Town of: gO• t k To the Inspector of Wires
By this application the undersigned give'-nlotic/e!�oof-�h�isso�or h intention to perform the electrical work described below
Location(Street&Number) 2 Z 141GL�'v -CI44
Owner or Tenant -3-hc K R/Zlo 2 Telephone No. 413- $7q- y 7132
Owner's Address / / , �jt a7114 Q t: 3
Is this permit in conjunction wit build g permit`' Le No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service>de Amps 4d o ;c.75/O Volts Overhead Undgrd❑ No.of Meters /
New Service Amps i Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity J.- /s4?Pl f -a 0 Aia-P
Location and Nature of Proposed Electrical Work: 1
LComplettc of the folio ring tahle may he',von.d h :re Inspector f iS
No.of Recessed Luminaires of Ceil.-Susp.(Paddle)Fans No.of Total
1No. Transformers KVA
No,of Luntinaire Outletsear No.of Hot Tubs Generators KVA
1No.of LuminairesOSwimming Pool Above ❑ In- ❑ No.of Emergency Lighting
, grnd. grnd. Battery t.inits
jNo.of Receptacle Outlets 8No.of Oil Burners FIRE.ALARMS tio.of Zones
No.of SwitchesNo.of Gas BurnersNo.of Detection and
Initiating Devices
Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
V'o.of waste Disposers Heat Pump I Number Tons KW No.olSelf-Contained.
Totals:; Detection'Ale/ting Devices
!No,of Dishwashers / SpaceiArea Heating KW Local { Connect it Other
1 t � Connection J
(Heating Appliances K`,� Security S�vst•ms:"
'No.of Dryers No.of Desires or Equivalent
lNo.of Water ,No.of No.of 'Data Wiring:
Heaters h�� Signs Ballasts No.of Devices or Lyuisaleni
7'elecommunication,W iron;:
No. livdrornassage Bathtubs No.of tutors Total HP No.of Des ices Or Equivalent
OTHER:
Estimated Value of Electrical Work. (When required by municipal policy-/
Work to Start: g-S-..Z5 Inspections to be requested in accordance with MEC Rule l J.and uhor.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 cover ge is in force,and has exhibited proof of same to the permit s suing office
CHECK ONE INSURANCE Mr BOND ❑ OTHER ❑ (Specify L,//9e/L/Ty 7--f5'-as
I certify, under the pains and penalties of perjury,that the information on this application is rue and complete.
FIRM NAME: EDw/400() *a./ Doe.ew LIC.NO.: 37i/q-
Licensee: Signature e.....440/~ LIC.NO.:
O/O07 Bus.Tel. No,:y/.7 Vre77"1,/yi'
Address: A0'1 941AVEGeP Sr' D. rLe LCfl 'rO w.4.' -.oil 41 Alt. I el. No.:
*Per M G.L .securit work requires Department of Public Safety"S"License Lie \ i
OWNER'S INS!RANCE W-+etti'ER: ! am aware that the Licensee Joys nor hate the liability insurar ei c,r.erilee normally
required by law. Bc my siananire below. I hereby,waive this requirement I am the(check one E owner ❑owner's agent.
Owner/Agent t
Signature Telephone No. PERMIT FEE: 5
V it F D 14200J L t.-CT (c
ti C
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