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; �-� Cornmonwealih ot Massac c� � � � � � ��n=,�v5�cmiy
Departmenf of Fir,-e-Serv es ' Pe�c o. � 'US � //IS
BOAR� OF F1RE PREVENTION REG LATTONS O 2g05up cy nnd Fee Chccked
� HEALTH . t� 9] leaveblank) .
� APPLICATION FOR PERMfT TO PER�ORM ELECTRICAL �'/J�/�'�`q�''p^iK
i - All work to be perfomted in aetordonce with the Massa�husetts Elecficai Code(MfiC),52 C�I�OOf,/ � 'r �"�
'(PLFilSEPRINlININKORTYPEALLINFOR4f.4T10A9 Dute: ,S f �
City or Town.of: �n+�b�r �a R �ou �To the Lupector of Wires: &�, \ . �� , �
By this application the undersigned gives notice of his oc her intention ro perform the elechical work deacribed be �
Loc�tion(StreetScNumber) I � -l- �3 �jP• Ma Parcel ��
� P ::,
i Owner or Tenaat �' � J ! Tetephoae No. ,�3`{-.�S(�/� (,,�
I O�vner't Addresa _ �7 �� ' � j2'� L,. Vc� R'Y170c.e \ �
� Is this pvmit in coaJuncBon tvith a buildifng permit? Yes No Q' (Check Appropriate Bos)
� Purpaae otBtildin��u.6�i�, rn e '�t � Utiliry Authorization No. {L/� 7 a2 S^o�T-
Ezistine Service? Gp Amps i6 3 O Volts Overhesd Q� Undgrd ❑ No.of lteters
Ne�v Service �L�U p,mps �0 u Volts Overhead !� Und�rd 0 Yo. ot 1�leters
Yumberbf Feeden and Ampucity �f� ��� T/�N�-/
LoeaHon nnd Natu/re otProposed Electrtenl�Vork: ��s�// ����;C yy�a R �T�,�
s�/sdhr �o�� d-�le 2 m • ' � .
- Com (etion o/r6e/'o(lo�rin table nmv be waived bv thelns eetor ojfWres.
No.of Recessed Fixtures Yo.of Paddk Faas o,o ota
Transtormers I{V�
*fo.oCLighHng Outlets No.of Hot Tubs Generators ��
Yo.of Lighting Fistures Swimming Pool � ove � n- � i o.o mergency ig aaB
rnd. rnd. Batterv UNts .
�No.of Iteceptncle Outlefs . No.oC Oil Burners FIRE ALARhIS. Yo.af Zonee
i`io.of Switcha No.of Gus Burners o.ot etecuon an
Initlatln Devica
� No.otRanges No.otAir Cond. .t°Ong No.of Alerting Devices
� No.ot Waste Disposers eat ump . um er ons __ i o.o e - ontuuie
Totals: "- DetectioNAlerdn Deviees
Vo.o£Dishwashers SpacelArea Heatlng KW La��� � Canae edon � ��er
� No.otDryers Heating tlppliances �y ecur ty vsteras:
No.otbevices or E uivalent
i o.o ater � i o. o � o,o Data Wiring:
He�ters Si ns $a�i�sig . No.af Devices or E uivalent
� i(o.Hydramnssaea Bathtubs No.o[r[orors Tota!HP e ecommuaications inn�;
� No.af Devices or E uivalent
;r oz�x:
�
-=- ,demc6 addiriwm!d:rui!i/destred,or a.r nquirod b.v�he Inrpecror of�vi��rs.
-9 INSURAiYCE COVERAGE: Unleai waived by the owner,no permit for ttu performance nfelectrical work atny issue unless the
licensee prov{des proof of liability insurance ineludia¢"compleud opecation"covecage or its substaatial equivatent. 1'he undusigned
certifies that such coverage is in fdrce,aad has e:chibited proof of su� to the permit issuing o ce.
� CHECK ONE: INSURANCE (�HOND ❑ OTFiER ❑ (Specify:) /c�� � �_�
° (Eapiracion n�e)
Estimated Value of Elecaical Work: �G O O (When required'by muaicipal policyJ
J Work ro Stut: �, g �gpecaons to be mquested in accordance with MECRuIe 10,aad upon campleuon
� !certify,unJer Hte pai d penalties af pery't�ry,tl�at the injormatiae on r/�is applicetiun $tsue axd comp/rte.
� FIRM NAME: LIC.NO.: /3,�V.3
;i Licensee: Signature LIC.NO.: �„2� �7�J
,t (�IaPP[icab[e, ennr p� 'in�h[b snserty��(me.J /'� �� Bus.Tel.iYa.: 3 7 -•Gf Y�1 ..
Address:_����f;�i���7� �,GIL3 u��R n��,,� plt.Td.No.:
O WNER S INSIJRANCE WpIVER:•I am aware that tha Liccnsee dors nor have the liabiliry imurance coverage nom�atly nqui�d by
taw. By my sigMtw�below, I horeby waive tlsis requirement I am the(check oae) Q owna ❑owner's acent.
(lwner/Aamt � — � '
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