HomeMy WebLinkAboutElectrical Permit APPLIaAT10N FOl� PERMIT TO PERFORM ELECTRICAL WORK
� All w�rk to be performed iq accordance wrzh the Massachusetts E.teccrtm(C�� (MEC),527 CMR 12.00
� y�
� � �/ ----'_ -` "j (OFFICE USE ONLY)
�e T��I I �� _�I BY
I i,;N 1 +2�J�F � Fee: $ �( � Lr�l
PERMIT NO. ���`�
(PLEASE PRINT IN INK OR TY " ` "� � � ��� �
9I.L}�1fFQ Z'I Date: � p
To the Inspector of Wites: By thi$ p icahon the qndersigned gives �o�
work described below. ���PP, p on to perform the electrical
Location (Street&Num ' �,.� JUN 1 6 2
• Owner or Tenant � �
. � �'1EAL T lephone
Owner'sAddress /��tko
� Is this permit in conjunction withla building pemvth ❑ Yes �No
(Check Appropriate Box)
Purpose of Building �l✓���--u�_
Uti(ity Authorizarion No.
Existin Service I
8 Amps / Vopts Overhead❑ Undgrd❑ No. of Meters
New Service AmpsT i_V�ts OverheadQ Undgrd[a No. of Meters
Number of Feeders and Ampacity� i
� Location and Nature of Proposed�lectrical Work:�LG`���/�Z� Pj��,� P�5 -�-��� ��,�
i
� �� Co letiono the a[lowrn tabfe bewaivedb thelns ectoro Wires
� No. of R e se Fix r o. of eil- No.of otal
. Transformers KVA
T No. of Li htin Outlets � No. of Hot bs
�_ Generators KVA
No. of Li hdn Fix[ures °e �+7 n- No. of inergency Lighung
�, Swimtnin P�ol d. t.1 d. ❑ Batte Units
No. of Receptacle Outlets No. of Oi]Buhners
FIRE ALARMS No. of Zones
No. of Switches No.of Gas B mers o � ecnon ar,
Initiatin Devices
No. of Ranges � No. of Air Co�� d. °�
Tons No. of Alerting Devices
No. of Was[e Disposers eat mp ' um r ons No. of Se16Contained
� � Totals; —'— 7k�Mion/Alerting Devices
No. of Dishwashers Space/Area H� ting KW Municipa!
Local Q Connection ❑ O[her
� No. of Dryers Heating qppli$nces KW Secufity Systems:
No.of Water No.of No. of No.of Devices or ui vatent
H��� Kµ' I Si ns �� Ballasts Data Wiring
No.of I3evices or uivaient
J No. Hydromassage Ba[htubs � No. of Motors�'�. Total HP TeIecommunications Wiring:
� , No, of Devices or uivalent
�INSURANCE COVERAGE: Unless waivel by the owner, no pqrmit forahe�orrman e of elecL[n�allwo k maysbe �sued unle the 1 cense¢plo�deSs.
proof of tiability insurance including "co pleted operatiod'coverage or its substantiat equivalent. The undersigned certifies that such coverage is in
force,and has exhibited proof of same[o e permit issuing offi�ce.
CHECK ONE: INSURANCE BOND 6
� I ❑ I O'I'HERQ (Specify:) ��
Estimated Value of,Electrical Work: � I x uo ace>
Work to Start: �//T/��` (�'hen required by municipal policy.)
�.—,___.Ins ections to be requested in accmdance with MEC Ru]e 10, and upon completion.
I certify, under th ns.and penaities f perjury, t}�at the information on this appiication is uve and complete.
FiRM NAME: � c�
Licensee: Q _ , y LIC. NO. /6s ;j�
Signalture LIC. NO.
Qf applical}(e, enter"exempP' in t6e li nse number line.)
Address: �' ��j �sy ' ,e Bus. Tel. No._ sz,x`
YlCYiv� s.�f� 011;�
OWNER'S INSURANCE WAIVER. I atn a ,are[hat the L�censee dces not have the liability insurance coverage�w���y�y.aw.By my signature
below,I hereby waive this requirement. I at�the (check o�e)ow�er Q owner's agent�
OwnedAgent
Signamre
IRe�.oyrop� , Telephone No.