HomeMy WebLinkAboutE-09-923 #82 Electrical Permits• Commonwsa o`cc%I%a�saclu stfd Official Use Only
aUsPa imenl o` tcrs �swicse Permit No. i ri (D9 — l 20
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee CheckedRev. 1/07j leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC). 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE LL INFORAM ION) Date:
City or Town of: _ K CJ To the Inspector of Wires:
By this application the undersigned Jives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 17
Owner or Tenant 1 c
Owner's Address i 1s— 0
Is this permit in conjunction with a building permit? Yes ❑ No ❑
Purpose of Building Utility Auth
Existing Service Alm / Volts
New Service Amps I Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Overhead ❑ Undgrd
Overhead ❑ Undgrd
2-
Telephone No. L g 5Q,1335
No. of Meters
BUILDING DEPT
1 G J
Completion of thefollowiniz tab e may be waived bv the Inspector of Wires.
No. of Recessed Luminaires
No. of Cell.-Susp. (Paddle) Fans
o. o ota
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ n- ❑
ad. nd.
o. oEmergency g ng
Bette Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
N-o-.—of Detection an
Initiating Devices
No. of Ranges
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
eat ump
Totals:
, um_ gF
ons
o. oSelf-Contained
Detection/Alertinz Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ MunicipalEl Ufher
Connection
No. of Dryers
Heating Appliances KW
urity ystems:
No. of Devices or Equivalent
o. of Water,
Heaters
o. o o. o
Signs Ballasts
Data Wiring:
No. of Devices or f4givalent
No. Hydromassage Bathtubs
No. of Motors Total HP
a ecommumca onsWiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
- Work to Start: 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
LJ 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:)
certify, under the ins and pe allies of perjury, that the information on this application is true and complete.
�- IRM NAME: KIQ C, e /M LIC. NO.: �
Licensee: ( }� P -�- I y� Signature LIC. NO.: /J
(If applicable ter "exeemmpl" in the number line.) Bus. Tel. No.
Address: S , /' G� Alt. Tel. No.: - 6 4 / 2
e , *Per M.G.L. c. 147, s. 57461, security work requires Department ofYublic Safety "S" tense: 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 agent.
Own tore nt PERMIT FEE. $
Signature Telephone No.