HomeMy WebLinkAboutBLDE-26-469 RECEIVE ®
A rs s -`1l 2026 4ommon wealth of Massachusetts Official UseOnly_,
Permit No.: ztu 0
Department of Fire Services Occupancy and Fee Checked:
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Bulgy=:' "� __ OF FIRE PREVENTION REGULATIONS [Rev. 1/2023]
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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
City or Town of: YARMOUTH Date: a 3/3l J ao a f.
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&Number): ( 13ccezy Po:n4. Ra Unit No.:
Owner or Tenant: ( c'4w Corcij Email: /V4.4-4-4.e GFTcc.[uca/,•on. ores
Owner's Address: '7$S4c, Rc� lnlillio,nsbur , NIR o l o46 Phone No.: (//3' qqa-36�y
Is this permit in conjunction with a building permit?(Check appropriate box)Yes❑ No El Permit No.:
Purpose of Building: S;nglt corn;/y 01140;4 Utility Authorization No.:
Existing Service: /OU Amps /ao / .2 io Volts Overhead Underground❑ No.of Meters: Z
New Service: a,O c) Amps tao /440 Volts Overhead ►a' Underground❑ No.of Meters: 1-
Description of Proposed Electrical Installation: To Mill /)Uv Sexy , fa- «,,/ pone/
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-Gmd.❑ Hot-Tub❑ 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 ❑ 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❑ Level 1 ❑ Level 2❑ Level 3❑ Rating:
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 30 (When required by municipal policy)
Date Work to Start: O4-00°a6 Inspections to be requested in accordance with MEC Rule 10,and upon completion.
FIRM NAME: A-1 0 or C-1 ❑LIC.No.:
Master/Systems Licensee: LIC.No.:
Journeyman Licensee: Roi D• L LIC.No.: Sq' qQ 8
Security System Business requires a Division of Occupational Licensure"S"LIC. S-LIC.No.:
Address: Joy /V orfti k,es f Z4, Imie54,..-9/e4, M4 O/c 2
Email: Rory oe g ,s9r»a,•/. Crv,` Telephone No.: 171j.3' 3-20- 8 7c/7
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
Licensee: — Print Name:Rv, P �i,iyte7tti:�rn Cell.No.: y/.3- -8 7417
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 e to the permit issuing office.
CHECK ONE: INSURANCES 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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