HomeMy WebLinkAboutBLDE-26-11 RECE"E-D
Commonwealth of Massachusetts o t lUsygniy
Permit No.: l t
MENT Department of Fire Services Occupancy and Fee Checked:
ButLDI OF FIRE PREVENTION REGULATIONS [Rev.I/2023J •
t3`1
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527,713,00'R
City or Town of:_YARMOUTH Date: -i
To the Inspector of Wires:By this apt' t' ,the undcrsi in i a notices of his or her intention to perform the electrical work described below.
' Location(Street&Nvibea l_ S i/i`�f/kJnit No.:
Owner or Tenant: ��pO e ,• nt Email: q
Owner's Address: 2, ST YY t Afi(V`/ rrl/�y Phone No.: 63/ 7 04!2
Is this permit in conjunc //4ce
ith a buildiin a t7(Check appropriate box)Yes 0 No 0 Permit No.:
Purpose of Building: p�P Ut' Authorization No.:AA/AV44it�Lfr,fa..�
Existing Service: Amps NI /2 0 Volts Overhead Q J nderground❑ No.of Meters:
New Service: /)Amps/14 /a� Volts Overhead Underground❑, No.of Meters:_ _
Descriptign of Propomd Electrical I allattiiion: t f////
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 Alann System 0 No.of Devices:
Swimming Pool:In-Grad 0 Above-Grad.0 Hot-Tub 0 No.of Self-Contained Detection/Alerting Devices:
No.Oil Burners: No.Gas Burners: Video System ❑ No.of Devices:
No.Air Conditioners: Total Tom: Telecom System 0 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 Supply Equipment:
No.of Modules: Roof-Mount 0 Ground-Mount 0 Level I 0 Level 2❑ Level 3 0 Rating:
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Bleep �y1f• (When required by municipal policy)
Date Work to Start: / 1i7 Ins`uections to be requested in accordance with MEC Rule 10,and upon completion.
FIRM NAME: f 6f 7 A-1❑or C-I❑LIC.No.:
Master/Systems Licensee: � LIC.No.:
Journeyman Licensee: Z111/10 // "5� . LIC.No.: 4IX9 38
Security System Business requiresref a Division of pcupational Liecnssure"S"LIC. S-LIC.No.:
Address: ( /V t 14//l ileti�/,Ap�''`i`+ �'�/7 �') /�(q
EmaEmail: Telephone No.:L/ypo //1`%II/b
I certify,under the pains t penalties of perjury,that the in vnati t on this pplicallon is true and comp! e.. [
Licensee: Print Name: �1 eft / 5- Cell.No.: _00- —7Of(
INSURANCE C AGE: nless 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
in forceandN has exhibited proof s e to thepermit issuing office. / � ��C �� J/,/J rr
CHECK ONE: INSURANCE BOND❑ OTHER❑ Specify: GD p P 2 Cot / A 9
OWNER'S INSURANCE A ER:I am aware that the Licensee does not have the liability insurance coverage norm Ily
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.: