HomeMy WebLinkAboutE-05-376 control house Electrical PermitsAPPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00
TOWN OF YARMOUTH
no ti-19V
(OFFICE USE ONLY)
13
Fee: $
PERMIT NO. ci-7 ^ Ob r .3 76
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: l & -1,1/- !` J
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) 2�
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? No (Check Appropriate Box)
Purpose of Buildingr� ��ci�/DnJ' Y4,y�Utility Authorization No.
No. , 7557--G9 7.
Existing Service Amps / Volts Overhead Undgrd C1 No. of Meters
New Service c 0 0 Amps 4-30 /c�) VO Volts Overhead0- Undgrd �No. of Meters
Number of Feeders and Ampacity
Location and Nature of
electrical Work:
Completion of the following table may be waived by the Inspector of Wires
No. of Total
o. of Recessed Fixtures
No. of Ceil.-Sus . Paddle Fans
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
Above rj In-
No. of Emergency Lighting
No. of Lighting Fixtures
SwimmingPool rnd. gmd.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Detection and
No. of Switches
No. of Gas Burners
Initiating Devices
Total
No. of Ranges
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pump
Num er
— — —
Tons
—
KW_
No. of Self -Contained
No. of Waste Disposers
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Municipal Other
Local Connection
No. of Dryers
Heating Appliances KW
Secutity Systems:
No. of Devices or Equipvalent
No. of Water
No. of No. of
Data Wiring:
Heaters KW
Signs Ballasts
No. of Devices or Equivalent
Telecommunications Wiring:
No. Hydromassage Bathtubs
No. of Motors Total HP
No. of Devices or Equivalent
Attach additional detail if desired, or as required by the [nspcctor of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may be issued unless the licensee provides
proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certi®Vfhal t8h� 7age is in
force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND OTHER(Specify:)�
_ (Expiration Date / L
Estimated Value of Electrical Work:�.1'�Q"i (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and enalties of perju , that the information on this application is true and complete.
NAME: ' LIC. NO.
L�hsee: i Signature - LIC. NO. CJ
(If applicable, enter "exempt" ' the license number li ) us. Tel. No.: 9 7 ir- Gam/ 7O c
Address: % ;�� ��� ��-a- .,✓� + X� C--g73 Alt. Tel. 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 Cl owner's agent. C3
Owner/Agent
Signature Telephone No.