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1V1024 i iCommon wealth of Massachusetts Official Use Onl
*_— Permit No.-Z-5--`jZ
€mn.- Department of Fire Services Occupancy and Fee Checked:
BUILDI + -- i-=='t MENT p
c TIF 4, _S. [Rev. 1/2023]
BY - =;=,�_�_ � D OF FIRE PREVENTION REGULATIONS
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CM 12.00
City or Town of: 1A/f,c-1- )''.r/ho644 ii Date: 101,-- 2e1-14
To the Inspector of Wires:By this application,the undersigned Oyes notices of his or her intention to perfonn the electrical work described below.
Location(Street&Number): 2.1 rt. v. ,,,- L t 1.a,w Unit No.: i
Owner or Tenant: Ctcy 11( Email: OVIEIct-t1c-A1 lei i7ga6, -*il.c-cy"-,
Owner's Address: 17 kit.b cell Lwn-c. Fit-s41k„ br► Phone No.:
Is this permit in conjunction with a building permit?(Check appropriate box)Yes ElNo VPermit No.:
Purpose of Building: Ai,,,ta,h,, Utility Authorization No.:
Existing Service: `Z(�p Amps IZo /2 0 Volts Overhead Ell Underground El No.of Meters: I
New Service: too Amps MO /24o Volts Overhead[2 Underground❑ No.of Meters: 1
Description of Proposed Electrical Installation: uteri,, -(v t-/ SUGki,
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-Grad.❑ Above-Gmd.❑ Hot-Tub❑ 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 0 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 1 ❑ Level 2 0 Level 3 0 Rating:
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: NA- (When required by municipal policy)
Date Work to Start: 1V-0,1 Z.Vt-( Ins�pections to be- requested in accordance with MEC Rule 10,and upon completion.
FIRM NAME: 06-A.10 JarMC4/414`4`r' E!&MAY-1 G 70(4" A-1 ❑or C-1 ❑LIC.No.:
Master/Systems Licensee: n j LIC.No.:
Journeyman Licensee: Øc.v,jjl /�tvv�4 30'✓1. LIC.No.: reI-/C �-
Security System Business requires a Division of Occupational Licensure"S"LIC. S-LIC.No.:
Address: 3 7 S o v.-1]-1- S f. 4A— Sv w1'� fi,I-iki g/
Email: PIA- kILVrlc-t-i 13 JGpr'N1. forte ! Telephone No.: 1?ig 7---elff Li
I certify,u r the pains nd nalties of perjury,that the 'nformation on( this application is true and complete.
Licensee: Y,r� Print Name: oyt L !t
� ►, a' Cell.No.: 4/7-4/7-19 6f
INSURANCE COVERAGE:Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee
provides 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 same to the permit issuing office.
CHECK ONE: INSURANCE[r BOND El OTHER El 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.:
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