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..UaParfmarrt o f }ira �arvics� Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
ev. 1/071 eave blank
APPLICATION FOR"PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code Q'IEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7-1-r = 1141
City or Town of: yARMOUTH To the Inspector of Wires:
By this application the pndersigned gives notice of his or h intention to_perform the electrical work described below.
Location (Street & Number) , TLD �lQIj% -
r
er or Tenant /0".,v
s Address _0^0r al,11 �
Telephone No.
, a permit? Yes ❑ No '� ,,'is this permit in conjunction with �A� . , c� (Check Appropriate Box)
urpose of Building Y , *7/ building pUtility Authorization No.
Existing Service O Amps `folAW Volts Overhead ❑ Und rd
g 45 No, of Meters
New Service Amps / Volts Overhead ❑ Und rd
1; ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
4 Y
Com letion o the following table may be
No. of Recessed Luminaires
No. of Luminaire Outlets
No, of Luminaires
No. of Receptacle Outlets
No. of Switches
No, of Ranges
of Ceil.-Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool Sn
No. of Oil Burners
No. of Gas Burners
No. of Air Cond.
waived
Generators KVA
ElIn- ElI o. o Timergency ling
OrnA Rnfi-e.... �e�
No, of Waste Disposers
treat Pump
I Number
Tons
Totals:
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Appliances
KW
No. of ater K�,
Heaters
No, o
o. of
Si Zns
Ballasts
No. Hydromassage Bathtubs
No. of Motors
Total HP
OTHER:
ALARMS JNo. of Zones
4o, of Alerting Devices I
❑municipal
Connection fie'
I'M or Devices or
:a Wiring:
No. of Devices or
ecommunications
No. of Devices or
rf / Attach additional detail if desiret4 or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 4 jb (When required by municipal policy.)
Work to Start: -;0 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
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE- BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains andpenalties� ,00I perjury, that the information on this application is true and complete
FIRM NAME: 1.-fits ���L %Gj�fifyR��''� iYIi9��/�N�.r/�a LIC. NO.:
Licensee: �— 1p,.,' Signature IC. NO. Z'36
(If applicable, enter "exempt - in the license number line.)
Address: Bus. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt Lic. No.
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 a ent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $