HomeMy WebLinkAboutE-99-96ci
ts
/
The Commonwealth of Massachusetts
Deportment of Public Safety
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
Otitee Q Only
hreic b.
occupancy a roe crocked
3/90 (lea.e 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 INR OR TYPE ALL I2iF0R1 MON) Date a 9 39
City or Towa of Yo.r rel D %)+ I1 To, Insp of i es:
The undersigned applies for a permit to perform *the electrical work r3be be w. fJ
/
Location (Street 6 Number) 8 9. /7 e res tAtp 1'
Owner or Tenant l� p y-6 a ra. k Y�ts 4►- c �e
Owner's Address Z� b 04-P 11 U 1
DIs this permit in conjunction with a building permit: Yes no ❑ (Check Appropriate Box)
Purpose of Building S ke dY Utility Authorization NO.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service. Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity n /�
Location ta�nd Nature of Proposed Electrical Work l r lvi t r1t %1✓4t ttie 0�1ar hancQ
T�.ec�tl� FVo•vk }toJsQ (o rQ�llev tece�}c.l� I 1 u !tlw.PSw,Nk ovi� a/eeir,.ilro'�
No.
of Lighting Outlets
No. of Hot Tubs
No. of Transformers Total
KVA
No.
of Lighting Fixtures
Fc»-
1,K
Swimming Above In-
8 Pool grnd. ❑ grad. ❑
Generators KVA
No.
of Receptacle Outlets
P
i0
No. of Oil Burners
No. of Emergency Lighting
BatteryUnits
No.
of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
and
No. of trot Devionices
Initiating Devices
No. of Sounding Devices
NDetection/Slf oundingeDevices
Local ❑ Municipal ❑ other
Connection
No. of Ranges
No. of Air Cond. Total
No. of Disposals
No. of Heats Toms - ToKtaal
No. of Dishwashers
Space/Area Heating 0?, 5 KW
No. of Dryers
Heating Devices KW
No.
of Water Heaters
KWNo,
of o. o
Ballasts
Low VoltageSigns
Wring
No.
Hydro Massage Tubs
No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Li ilit 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 coverage by checking the appropriate box.
INSURANCE BOND ❑ OTHER ❑ (Please Specify) tl3 iu
ttxpi,atio a
Estimated Value of Electrical Work $ / O O 0-
Work to Start o? AY Inspection Date Requested:
Signed under the penalties of perjury:
FIRM NAME
.rn
Rough k,L Qo// Final Hl.// e.A
LIC. No. /083 3
LIC. NO. E.21-/20
Addres . 2 (rid✓ ..e .Z73Pus. Tel. No.4F.23 0277
Alt. Tel.'No.
OWNER'S INS CE WAIVER: I am aware that the Licensee does not have the insurance coverage or is sub-
stantial equivalent as required by Massachusetts General wsa—L , 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
1 w e
WIRE INSPECTOR'S DEPARTMENT
YARMOUTH TOWN HALL
SOUTH YARMOUTH, MASS. 02664
Fee
V '
w.
Name of Jo
r � i
Name of Electrician
Location ate
0�4- ' e4 X�4v 31-