HomeMy WebLinkAboutBLDE-26-210 (2) SCOMMOnureaK 01///a�ad th Official Use Only
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t-;- 3* BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
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APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Feb, 17 4'
City or Town of: yjlcMbDi.k. To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) I
Owner or Tenant 9106 "+ _JO y Soft Telephone No.
Owner's Address
Is this permit in conjunction wi th a building permit? Yes IN No ❑ (Check Appropriate Box)
Purpose of Building Olt_rAti,Iy )II tj� Utility Authorization No.
Existing Service Amps 191) /a40 Volts Overhead gi Undgrd❑ No.of Meters 1
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: LLYiNV4. O LOAN._ rGDM A MI VVOA.
Completion of the followingjable may be waived by the Inspector of Wires.
Total
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.ofKVA
S Transformers KVA
No.of Luminaire Outlets 4 No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ri In- ❑ No.of Emergency Lighting
3 grnd. grnd. Battery Units
No.of Receptacle Outlets i' No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.on Detection and
7Initiating Devices
Total
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
p Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW cal❑ Municipal Connection ❑
Lo Other,
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring.
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
J Estimated Value of Electrical Work: 7�. 00 (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
.t undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 1 BOND ❑ OTHER ❑ (Specify:)
Q` - I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: LIC.NO.: rLicensee:lf'EA Ut1iit Signatur04p1
LIC.NO.3ja
(If applicable,enter' emp("in the li se number AN.) Bus.Tel.No.•
Address: (OYJ £IL?Frj' �j, £(1n 15 Mil. 0r• r Alt.Tel.No.:,
*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
75 required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner 0 owner's agent.
(17NOwner/Agent PERMIT FEE:$
Signature Telephone No.