HomeMy WebLinkAbout195 Rte 6A0020:iic, 0_.e Only
The Commonwealth of Massachusetts
O _ Department of Public Safety
Occupancy 6 Fee Checked.
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12-00 3/90 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00/
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 52/2 / 9 9
City or Towa of �t 11 X,N7,C114-1, To the: spectoQ f Wire
The undersigned applies for a permit to perform the electrical work des ed
Location (Street & Number)j 1 / 5- 'p—i"'e. tP Gq I r,
Owner or Tenant %�' "t9 `e L- -f- -75i ,,
Owner's Address `
Is this permit in conjunction with a building permit: Yes ❑ No (Check Appropriate Box)
Purpose of Building k''CS' eo-C-- ` -c - Utility Authorization NO.
Existing Service & O Amps IICI /Z Volts Overhead E3Jadgrd ❑ No. of Meters— _
New Service Amps '/ Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location APi Nature of Propgsed Electrical Work C4-1
/,1 4 L A/axN-r
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers Total
KVA
No. of Lighting Fixtures
Swimmin Above In-
grnd. ❑ grnd. ❑
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. Emergency Lighting
Batteerr Units
No. of Switch Outlets
No, of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Total
No. of Ranges
No. of Air Cond. tons
Initiating Devices
No. of Sounding Devices
o. of Self Conta
NDetection/SoundingeDevices
Local ❑ Municipal ®Other
Connection
No. of Disposals
No. of Heats TotalTons Total
KW
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
y
Heating Devices KW
g
No. of Water Heaters KW
of No. o
Si ns Ballasts
Signs
Low Voltage
Wiring
No. Hydro Massage Tubs
No. of Motors / Total HP 3/1
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial
equivalent. YES ❑ NO[] I have submitted valid proof of same to this office. YES ❑ NO
If you have checked YES, please indicate the type of cov age by checking the appropriate box
3�
INSURANCE ❑ BOND ❑ OTHER R_(Please Specify) ��'r p
pi tion
Estimated Value of Electrical Work $ Tar'- ,,
Work to Start
Inspection Date Requested: Rough
Signed under the / penaltie of perjury�. / .p� —
FIRM NAME • 4- PI"17LM L1 14- /� LIC.
LIC. NO.
Licensee % G-ktz°f ov L N7Lb Signature Z7 iL 6
Address . �XiBus. Tel. No.(:?'
C- e
Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE S
Signature of Owner or Agent