HomeMy WebLinkAboutMiscellaneous - 190 COVENTRY LANE 4/30/2018 190 COVENTRY LANE
210/104.C-0126-0000.0
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This certifies that S
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ELECTRICAL INS ECTOR
Check # � � �SS���
i 551
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Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 11/991 leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 f,MR 1.2.00
(PLEASE PRINT IN INK OR E ALL INFO ATION) Date:�'
City or Town of: /�l To the Inspects of fires:
By this application the undersigned gives no ' e of his or her intention b perform the electrical work described below.
Location(Street&Number) CPY
Owner or Tenant ! ! J 6 rn Telephone No. .-
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead❑ Und rd
g ❑ No.of Meters
New Service Amps / Volts Overhead❑ Und rd
g ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
—Installation of Security system
t
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- T-5.0t Emergency Lighting
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.ot Detection and
Initiating Devices
! No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices
No.of Waste Disposers Heat Pump Number 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 SecurityNof Devices or Equivalent
No.o Water KW No.o No.o Data Wiring:
Heaters Signs Ballasts
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 lest 'cal Work: ' (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I certify, unde4thpoMinandpoenalties of perjury,that the information on this application is true and complete
FIRM NAME: Security , LIC.NO.: .l 5._3r
Licensee: John S. Bassett Signature LIC.NO.: 1533C
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: 603 594 5Q28
Address: Alt.Tel.No.:
OWNER'S INSURANCE WAIVER: I am aware that the Lic see 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/Agent77
Signature Telephone No. PERMIT FEE: $ ,