HomeMy WebLinkAboutE-06-889 # 106 Electrical PermitsAPPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, (MEQ, 527 CMR 12.00
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MATTACHEESE
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TOWN OF YARMOUTH
(OFFICE USE ONLY)
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Fee: $ ' 00
PERMIT NO. n
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7X?4 D ,S
To the Inspector of Wires: By this application the undersigned gives notice of his or her in ention to perform the electrical
work described below. / �J /,�// f
Location (Street & Numbed ` <� �� l `�� d C7
Owner or Tenant �� "'1,4� //�� Telephone No.
Owner's Address l6 er y � �� �c;) U �/,'' � �'/1 T� QG,, i`/F
Is this permit in conjunction with a building permit? 0 Yes ZWo (Check Appropriate Box)
Purpose of Building 44_ , Utility Authorization No. / S 0 3 C
Existing Service 61/ Amps / Volts OverheadO Undgrd 0 No. of Meters
New Service /4 4 Amps z-:� 1-20 Volts Overhead Undgrd ?1-" No. of Meters IA
Number of Feeders and Ampacity, �� �` ' ��Ax
Location and Nature of Proposed electrical Work:
ompletion of the following tab may be waived by the Inspector of Wires
No. of Recessed Fixtures
No. of Ceil.-Sus . Paddle Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Above In-
SwimmingPool grnd. grnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets y�
No. of Oil Burners
FIRE ALARMS
No. of Zones
.�
No. of Switches J 6
No. of Gas Burners E
No. of Detection an
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Num er
— —
Tons
— —
KW
— —
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers j
Space/Area Heating KW
Municipal
Local Connection Other
No. of Dryers I
Heating Appliances KW
Secutity Systems:
No. of Devices or E uipvalent
No. of Water
Heaters 4-5 KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. H dromassa e Bathtubs
y g
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
Attach additional detail if desired, or as required by the Inspector 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 certifies that such coverage is in
force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND O OTHERC) (Specify:) �'�/� 1�
Estimated Value of Electrical Work:_A S L (When required by municipal poli(Expiration Date)
mil+ Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
3 I certify, under the i s and penalties of perjury, that the information on this application is true and complete.
<v RM NAME: P'f"''7 12 C ✓JS LIC. NO.
censee: G�_-4--_ Signature LIC. NO.
(If applicable, enter "exempt" in the license um er ine.) Bus. Tel. No.: !/,� I
Address l 5� C t/YI /y/ t /C 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 owner's agent.
Owner/Agent
Signature Telephone No.
[Rev. 04/00]