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Commonwealth of Massachusetts
Permit No. z Z
Department of Dire Services
_KD "
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 11/99]. leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code EC),527 CMR 12.00
(PLEASE PRINT IN INK OR A F TI N) Date: '
City or Town of: To the Inspector of Wires.-
By
ires:By this application thI2T55igne glue ot'ce of his or he&ifi dto a rm the electri 1 work described below.
Location(Street&N ber)
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a buildYes.:❑ No
(Check Appropriate Box)
Permit
Purpose of Building Utilityual thorization No.
Existing Service Amps / Volts Overhead❑ Und rd
g ❑ No.of Meters
New Service. Amps / Volts Overhead❑: Undgrd❑ No.of Meters I�
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Installation of Security system
Completion of the followin table may be waived by the Inspector of Wires.
No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Lighting Outlets No.of Hot Tubs Generators KVA
No.of Lighting Fixtures Swimming Pool Above ❑ In- No.o mergency ig mg
rnd. rnd. Batt
e Units
No.of ReceptacleOutlets
No.of Oil Burne
�. PBurners FIRE ALARMS No.of Zones
� I
No.o
No.of Switches No.of Gas Burners
Detection an
Initiating Devices
No.of Ranges No.of Air Con Total No.of Alertin Devices
Tons g
Heat Pump Number Tons KW No.of Self-Contained .
No.of Waste Disposers Totals: Detection/Alerting Devices
No.of Dishwashers Spee/Area Heating KW Local ❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:
No.of Devices or Equivalent
No.of Water No.o .o No
Heaters KW
Signs Ballasts Data Wiring:
No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
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
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:)
(Expiration Date)
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.
l certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: kiwLIC.NO.: 1 r 1(
Licensee: John S. Bassett Signature ILI LIC.NO.: 15330
(If applicable, enter"exempt"in the license number line.) Bus.Tel.No.: 603 594 5928
Address
Alt.Tel.No. I
OWNER'S INSURANCE WAIVER: I am aware that the Lic, see does not have the liability insurance coverage normally i
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $ e