HomeMy WebLinkAboutMiscellaneous - 125 PEACH TREE LANE 4/30/2018 (2) it
Commonwealth of?Massachusetts Official Use Only
Permit N/andd
Checked
Department of s=ire Services
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BOARD OF FIRE PREVENTION REGULATIONS [Rev.Occupan11/991. (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 TY A ,F TI N) Date:_����
City or Town of: To the Inspector of Wires:
By this application the undersigne give ot'ce of his or her i tion to e rm the electri l work described below. i
Location(Street&Nu ber)
Owner or Tenant Telephone No. •
Owner's Address
Is this permit in con unction with a 6ui ing permit? Yes ❑ ,. T9 � (Check Appropriate Box)
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Purpose of Building Utility thorization No.
Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑: UndQrd El No.of Meters
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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
AboveIn- o.o EmergencyLighting
No.of Lighting Fixtures Swimming Pool rnd. ❑ rnd. ❑ Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners o.of Detection and
Initiatin Devices
No.of Ranges No.of Air Cond. TotaTons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number I Tons KW No.of Self-Contained ,
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:
No.of Devices or Equivalent
No.of Water No.of No.o
Heaters KW Signs Ballasts Data Wiring:
No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Talecom m.unicatiors Wiring:
No.of Devices or E uivalent
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: --f Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I certify, under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: Security12 ^ LIC.NO.: 15333
Licensee: John S. Bassett Signature LIC.NO.: 1533C-
(If applicable,enter"exempt"in the license number line.
Bus.Tel.No.: 603 594 S97$
Address
Alt.Tel.No.:
OWNER'S INSURANCE WAIVER: I am aware that the Lid.9fisee does not have the liability insurance coverage normally
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: $ 6
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