HomeMy WebLinkAboutE-99-637The Commonwealth of Massachusetts
Q Department of Public Safety
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BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12U0 3/90 et,,,,, ctena)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed In accordance with the Massachusetts Electrical Code. 527 CM 12:00
(PLEASE PRINT IN INR O`R'1REE ALL INIIFORMATION) Date `GJ 2-5-Q l
City or Towa of .q�lr, nie�tvp,,. - '` 11 To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical w%o� describe low. ,
Location (Street 6 H m r) V�IK: L (2CL(L_ (� j/{1L]�\1`
Owner or Tenant &-N 11P JIM <
Ower's Address /
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Is this permit in conjunction with a building permit: Yes RL No ❑ Bt Annronriate Box)
Purpose of Building ? JW �iC— Utility Authorization NO.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters_
New Service 2PO Amps k Lo / Z ,�(>Volts Overhead ❑ Undgrd ®- No. of Meters
Number of Feeders and Ampacity,
Location and Nature of Proposed Electrical Work C0AS1S FLT PAL-T62V4 1 �S"�'on L% o
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No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers Total
KVA
No. of Lighting Fixtures
Swimmin Pool Above In-
8 grnd. ❑ grnd. ❑
Generators KVA
No, of Receptacle Outlets
No. of Oil Burners
BaN. of Emergency Lighting
tte
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
Nof Detection and -
Ttons
No. of Ranges
No. of Air Cond.
In icia[ing Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Local ❑ Municipal Other
Connection
No. of Disposals
No. of pests Total Total
Tons KW
No. of Dishwashers
S ace/Area Heating KW
p g
No. of Dryers
Dry
Heating Devices KW
g
No. of Water Heaters KW
No, of No. of
Signs Ballasts
Low Voltage
wiring
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 r Insurance Policy including Completed Operations Coverage ofts substantial
equivalent. YESNO U I have submitted valid proof of same to this office. YES Lj NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE BOND ❑ OTHER ❑ (Please Specify)
d � Expiration ate
Estimated Value /Iof Electrical Work $ ( U J O
Work to Start tP 1 Inspection Date Requested: Rough CALL` Final L.It I.L Qr(._
Signed under a penalties of (.p�erj_ury: n
FIRM NAME ✓L2.10L_ \ .l.��M \ L �// 42.LIC. N0. A 14�
Address
Bus. Tel. No.�=�s2c o 6s I-
A[. Tel. No. C�'�£{.3 `j�j _
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage orb
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE $
Signature of Owner or Agent
637
Date
Name of Job
WIRE INSPECTOR'S DEPARTMENT
YARMOUTH TOWN HALL
SOUTH YARMOUTH, MASS. 02664
5
Fee
Name of Electrician
Location
pc�'2— 1 '.3'