HomeMy WebLinkAboutBLDE-25-588 _ -�-_ Commonwealth of Massachusetts Official Us0A,
Permit No.:
Department of Fire Services Occupancy and Fee Checked:
11= 24 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: y-/46 --,25
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&Nummber): g6 Cola I" 64ea47 Unit No.:
Owner or Tenant: (�a r t'I e — ay:/es' Email:
Owner's Address: Phone No.:
Is this permit in conjunction with a building permit?(Check appropriate box)Yes❑ No D Permit No.:
Purpose of Building: Utility Authorization No.:
Existing Service: /0 0 Amps //O / 2.?d Volts Overhead 0' Underground❑ No. of Meters:-
New Service: /0 0 Amps //d /,2211 Volts Overhead❑v'Underground❑ No.of Meters:
Description of Proposed Electrical Installation: ,e/o 4 c E e u/s i dr ace c,'ica / 6 Aie 'n,
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 0 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 Sup.y u= v E D
No.of Modules: Roof-Mount 0 Ground-Mount 0 Level I El Level 2 0 Level rL 4' •_ I_V
OTHER:
-----�_.__.__.__ MAY 0 5_MS___.
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: / Uv v (When requ?-edilyunuatipAllptt,adYJENT
Date Work to Start: Inspections to be requested in accordance with ion.
FIRM NAME: A-1 ❑or C-1 ❑ LIC.No.:
Master/Systems Licensee: LIC.No.:
Journeyman Licensee: lea h0 el IA t 4 LIC.No.: �22J5/
Security System Business requires a Division of Occupational Licensure"S"LIC. S-LIC.No.:
Address: f ��
Email: �C e' . /CU e d 4,c x , 7o/ ro m Telephone No.: siO b*?Sr/y
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
Licensee: Print Name: hP6/78r,1 Cell.No.: -3g/�
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 a BOND❑ 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❑
Owner/Agent: Tel.No.:
Signature: Email.:
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Fold,Then Detach Along All Perforations
g COMMONWEALTH OF MASSACHUSETTS
DIVISION OF PROFESSIONAL LICENSURE
BAD OF
ELECTRICIANS
ISSUES THE FOLLOWING LICENSE
REG JOURNEYMAN ELECTRICIAN cc
LEONARD KALBACH
PO BOX 112
HARWICH PORT,MA 02646-0112
22351 E 07/31/2022 633243
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
Fold,Then Detach Along All Perforations
COMMONWEALTH OF ASSA , ETTS
DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
ELECTRICIANS
ISSUES THE FOLLOWING LICENSE
REG JOURNEYMAN ELECTRICIAN E
LEONARD KALBACH 0
PO BOX 112
HARWICH PORT, MA 02646-0112 W
U
22351 E` 07/31/2028 757743
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER