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Home My WebLink AboutElectrical Permit � i � � � �_ _ �� The Commonwealth af Massachusetts .:.,`•�M� ' � �...,� ... � � . �C;�' 7}t�eritnent of Pu61iC Sajcty a<w�+•.r ��.. o�..w $OAAD OF flAE AAEYENTIQt( REGttLAifOliS S2J CMA 720q 7J90 ��,,,� ��,,,�� APPL1CATfON FOR PERMfT Ta PERFORM E�ECt'RlCAL WORK �C wr�b T�)a"lfofined In�cCerr.InGe.4�h A�N•.wchu�em FJecsriul Cod� 52T CMR 1S:CC (RS.EASE FRL'iS Eti 'IIiS O& TYPE dLL �L'AiSOZN.ATTOH) Daca �J --t`�� ''�8 City os 2ow of P.�T� �KL/h-dd�� 2o ch� L�.s,�ccwe of uiraa: . g� undersig+ed •ppiias tor a peraSt ta yecfoza chs slcccriui wrk dese::Ded � Inrisioa (Scteat L 2WaD4r) - Q 4�mer or Saune IJ Pmer'x Add:ess � " Is U+{� pe:�i,t Sa aoaJuaccioo vich a Duildia� penic: Yea ❑ Ho � � (Chec`cl�ppropilaca � � � � . Puzpasa at Sul1Q:a= Utilit7 Auc:ar y � � • - . . • ^ .. • F�cLcins Sazvie• �+pa I Yeln P+erlesd ❑ tkid;:d� No. 6f k4tsTs . t4v Secrice . A+ps 1 Yo7,cs Ova:»ead ❑ IIeGX:d❑ No. at kiaee:a ,. . - � '. .. '_' .. - Hiser oE Fesds.s and AapscitY ' . . . - // . Lacation and Nseura o! Tropased EleeCriul Wrk �//y/C�� J� .Fip�� wit�°L,"j'tdvJ �`t{yk.�f . 1 , . lto. ot Ligdcins Oucleu !y. of Ant iuba � Yo. of Srusa:orners =ocal � 1C+A ttq. af L2gh[in; Fizturts SvL�aint ?ool '�0"�❑ ja ❑ grnd. gr.+d. Ce-ara_ort R'lA Ho. of Recdpcac.e Ou.leta ;�. o£ 012 Suracrs yo. c: ?':et;cncr L�ih[in: Sat^err Un1Ca . � Np. o[ Svitch Oue?ets po, o[ Cas 9urn<r� e:RB ALd-Z`s5 Mo: of Zonea , No. of Rsnges � No, of Air Gnd. T�� Q•�°� ��°°[ioR and ' Iii..,..lt�1j �?CY�CC! No. af DLsposals � Yo, of H?eaaa� Iaul Io�l ,� of �yndi� Skvicca �r_ No. af Dt�h^+aare:a SpuelArc+ Neacln; 1W Yp• o£ Selt Conealaed� a7e:ect.onlSoundint Devicea . Mo. of Dcyera Haacin; Devicas RSt Taeal "�'nSci7a1 �0�`er . . ❑ Coneection ;to, o£ S+ater Hex:ars fCt �. of o. o �� yal,;�� " St a BatIoass �w1r'� . , tio, 8ydro riaryaSe =uDa Np, ot 'lacor� Saul i� .. . " Ot�'R: - . . . . . . . .. . . � .. . ' . . � ' - - - � L'ISSIMAH�' CGYE.L�f�C: Yurawne to r,R: requizeaencs af C�rsuhu:etts Cene:al Lavs � 2 h+ve a currenc 4faDillt Iasurancr Pollcy LncludL'rf Ca�placed Opsta[Soas Covazs;e ac !t� suDstanciat � �i equivalene. YES❑ NO (� I have suD�tc[ed valid praof o£ aue co ChLs o.<Ltce. YESQ NO ❑ �; � I£ you have checkcE YES. plea�t in4ict[e [Ae type of covarage D� cheaki^g G".e appcoprLy��c�e 6ax. r: v IVSUAANd' �8f'..ttD � trIIffR� (Pleast Speaif7? d/� 1~"�L� t.f�G .H".r Gb. . ,�, v � scp rac nn ap � �'„ Eic:aa4ed Valua a! ElaeLTi��l Vo[k 5 , � �T.� V f:ork to Surelo. as,��K Inspettian Oau &queaced: ' Roagh��lj Fina2 � � !-Jy} Si;�ed unCer .4he ��.enalties at perjury: . � S +L... FI+�!lN.V� -.� L21:.'N4. V �, Ltcemee ,,,�tL.r+ � i��.�- Siyvcuc� LIC. N0. .�n.1 '�Fy .� t?+ eaa.s,a I�ll.vw.„'�'',r2 �.9-� Ai�. :�i. ra. :� C"'t GS.NEi'S Ly5t1RA.tiC-T �AZ'fR: Z u avars chst ehe tismst� doe� noc have cRa ia�ss:u+me coverage or ca �u - , itancial aquivaleat as rer�ulred by !Li»acAusetta Cc:ceral vs�cn+c sy siZ:.arur� an khis peale ;t�"�,,, � applicaelon wives GRI.r requl:e�enc. .0.mes Agent (7lsase eReck er.e) • � ' Seleproaa Na. A£LYII �° S j5lynscure o£ Wner or A;en[ � I � .