HomeMy WebLinkAboutElectrical Permit APPLICATION FOR PERMIT TO�PERFORM ELECTRICAL WORK
All work ta be performed in accordance wich rhe Massachusetts Electrica!Code, (MEC),527 CMR 12.00
� � y� (OFFICE USE ONLY)
� � TOW F�MBU By
' �`"� MAY 2001 � Fee: $ I p�/S /�' o
� - � PERMIT NO._ F—n�� %(p �
B ��� I
(PLEASE PRINT IN INK OR TY " Date:,�Gu lR �1
To the Inspecror oF Wires: By this appGcacion the undersigned gives notice oFhis or her intention�pe�m the electrical work
described below
Location(Streec&Number) ? .�eJo ro�.�iS� �n(;
Owner ot Tenant_ �vi �y�'�Js Telephone No.
Ownei s Address
Is this permit in conjunccion wich a budding permit? ❑Yes �No (Check Appropriate Box)
Purpose of Building Utiliry Authorization No.
Esis4ng$ervice Amps � Volts Overhead❑ Undgrd❑ No of Mecers
,�, New Service Amps ( Volts Overhead❑ Undgrd❑ No.of Meters
�° Number of Feeders and Ampacity
x;
Locacion and Nazure of Pmposed eleccrical Work: (�v��' 4r i'1[� Ovw.n eJ.Q�,'�,t.-
I'`� . . .� . .. � . Can letiort o tbe is �tabk &weiued tbe Iw or o �rc.r
� '� � � � No.o Tota!
� - n Transformers KVA
�x� � o.of Li hci Oudets No. of Hoc Tubs Generators KVA
a A ve �7 In- �f Na.of Emer en Li hti
t'� No.�of Li htin Fix[ures Swimmin Pool rnd. U rnd. U Bacce Uni g � 8 �
No. o f R ecep�ac le Oudecs No.of Oil Burners FIRE ALARMS No.oFZona
�� �:b . No. of Switches No.of Gas Bumers No.o Dtteccion an
lni[iaci Devices
No.of Ran es To`al
8 No.of Air Cond. Tons No. of Alening Devices
Heac Pump Num r Tons KW No.of Self-Concained I
No. of Wasre Disposers Tocals: — Daec�ion/Aletting Devices I
No.of Dishwashers Space/Area Heating KW Local ❑ CM.onnecP on ❑ Other
�, No.of Dryers� Heating Appliances KW ��ry ys�ems: ,
No.of Devic
„�„�, No.of Warer No.of No.of Da�a Wiring: p '���
��.,-�a Heazea KW Si ns Ballaza No.of Devic (J/ n '�
No. Hydromusage Bachtubs No.of Motors Tocal HP L� Telecommunicaci Wiring:
No.of Devi no �..
. . r � ' �'',.
Attacb additioea!rktoi!iJdui or ar nquiru!by tbe lntpnYor o �ru.
_ INSU&fNCE COVEBAGE:Unless waived by che owner,no permic for the performance of decaical work may issue ' rovidee proof of �biliry '
�. iasuraace induding"complrnd opention"coverage or its substancial equivalenc The undersigned cert�es that such coverage�s m , p�( '
,�of samt ro che permit issuing oflica � � � ��
��`�CHECKONE: . 1NSURANCE� BOND� OTHER� (S c ) �IIOJIQ,Z
Pe ifY.
�scima[ed Value of Elxaical Work: ' (�p�cwnDace) '
r (When required by municipal polity.) II
Work�to Start: Inspettions co be requested in accordance wich MEC Rule 10,and upon completion.
' I mrtif};under the pai9,�nd penalties o�f pery'ury,�h�t che informacion on this application is aue and complem.
FIRMNAME: .Yt'Gv �+ I7�*�F—� ��c �c,No.
Licensee: Signacure w�P.�y..p LIC.NO. ���'��
(If app6cable,enrer"exempt"y'�the lice number lineJ Bus.Tel.No.: /-SoAr�/?�' ._S,Z21! I
Address: .�B ["L�...�IL C'f �..-7� p�c.Tel.No.:
. OWNER'S INSURANCE WAIVE&I am aaare tha[the Licensee dces noc have che liability insurance covera e normall
below,I hereby waive this requiremenc I and the(chak one owner 8 Y�1°�r°d bY�aw.By my signa[ure .�
) � owner's agenc.�
Owcer/Agent
Signature
� (xeu ovtrnt Telephone No.
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