HomeMy WebLinkAboutBLDE-25-1504 • __ Commonwealth of Massachusetts tAcial Use onlyS -/S
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Permit No.: /J - nl
kt Department of Fire Services Occupancy and Fee Checked:
•Il % BOARD OF FIRE PREVENTION REGULATIONS [Rev.I/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: �/7,,CS
To the Inspector of Wires:By this plication,the undersigned gives notices of his or her intention to perform the cice(ticnl work described below.
Location(Street&N er):o % (n i c? Unit No.:
Owner or Tenant: f^ Q Email: r a w P Tdet
Owner's Address: ,SGM e one No.:
Is this permit in conjunction_with a building permit?(Check appropriate box)Yes❑ No 0 Permit No.:
Purpose of Building: P) - Utiliqi Authorization No.:
Existing Service: Amps/.2c (a947 Volts Overhead Underground 0 No.of Meters: I
New Service: Amps / Volts Overhead 0 Un der ro nd❑ No.oy Meters:
Description of Proposed Electrical Installation: c fie if Ap±
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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-Grad.❑ Hot-Tub t� 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 0 Level I 0 Level 2 0 Level 3 0 Rating:
OTHER:
Attach additional detail if desiredd,orOireguired by the Inspector of Wires.
Estimated Value of Elec Wor / 0'7.-r (When required by municipal policy)
Date Work to Start: f/ Insp tiyns to_b[grequested in accordance wills MEC Rule 10,and upon completion.
FIRM NAME: /D/Y/ A-1 IDorC-1❑LIC.No.:
Master/Systems Licensee: /4 [�C� /J LIC.No.:
Journeyman Licensee: cY 7J'0 , LIC.No.:
Security System Business r uir`es/a Division ofOccupational Liccns/ure�"S" l/�� S-LIC.No.:
Address: �0 �l d� Y� i�t v v�Y/jr /"t�t V )‘7 S / C//
Email: '-f-/l4 dcleg.� e/ec +xc 2 G/f ii .COIF( Telephone No.: 7 74/�/`/_c9OS 7
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I certi ,mule the praJas nd penal( erjury,that the information on is op canton is true and complete.te / /
Licensee: rUU Print Name: I//o/�lGs 'rt(t er? J k. Cell.No.:7<r .5"`Y G26-4 7
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 s o the permit issuing office.
CHECK ONE: INSURANCE BOND❑ OTHER 0 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 0 Owner's agent 0
Owner/Agent: Tel.No.:
Signature: Email.:
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DIVISION OF OCCUPATIONAL LICENSURE
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LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER • • •
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DIVISION OF OCCUPATIONAL LICENSU. R E
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LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER . .
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