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HomeMy WebLinkAboutMiscellaneous - 25 BRENTWOOD CIRCLE 4/30/20189 7u V! FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does notrelieve the applicant and/or landowner from compliance with -any applicable local or state law, regulations or requirements. ****************Applicant C.- fills out this section***************** APPLICANT: eoo r C G,J 60A/ 1,fv �`'� S Phone LOCATION: Assessor's Map Number _50 q 41- S"7 Parcel Subdivision Sec'J7-,,,oi-D <<ee11(f Lot(s) ZA' Street _13,e6 -AJ r G-l00i::) 1.ee jC RECOM MMATIONS 07 TOWN AGENTS: Conservation Administrator Comments St.. Number 715 Use Only************************ Date Approved Date Rejected Date Approved Town Planner Date Rejected. Comments Food Inspector -Health Septic Inspector -Health Comments Date Approved Date Rejected Date Approved Z4Z Date Rejected Public Works sewer/water connections - driveway permit�i� j L3 Ly - ZS - g S Fire Department Received by Building Inspector Date 04e Tommonwealtll of �Itttsottcl�uoetto Department of Public Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use Only j Permit No. 0q., Occupancy & Fee Checked 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) City or Town of k 0 R- T- 14 ✓r ti D 0 V o the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) LUT X B )3 2 E%f T w U U D C l 0Z Ca ( F Owner or Tenant b %Z..0 U K V/ F-"_, 0 U AJ PT Y /-i4o 1-f 1�- S Owner's Address �/ 0/ A—it. 6 e (_ /? f D 6 F jZ D i NO D 0 u cn 1-4 4 0 V j Is this permit in conjunction with a building permit: I Yes No ❑ (Check Appropriate Box) `t Purpose of Building r c w 14 V_ 1 C _.Utility Authorization No. 5 U e / �� Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service 0-e) y Amps �_J Volts Overhead ❑ Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO O 1 have submitted valid proof of same to this office. YES 0 NO ❑ If you have checked ES, please indicate the type of coverage by checking the appropriate box. INSURANCE I BOND ❑ OTHER❑ (Please Specify) Estimated Value of Electrical Work $ Wprk to Start Signed under the penalties of perjury: FIRM NAME AAlOrt C_ C11 � Inspection Date Requested: Rough Final LIC. NO. Licensee ;"-r H 0,v y ¢ 1,y o& ( Signatu LIC. NO. 19- 0i 3 % S Address VCU (t D 1T F VE n f><is. Tel. No. SV9 -37)- -St 77 Alt. Tel. No. :OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts .General Laws, and that my signature on this permit application waives this requirement.. Owner Agent (Please check one) l Telephone No. PERMIT FEE �3061- r0 (Signature of Owner or Agent) 1✓h (Expiration Date) TOTAL No. of Lighting Outlets No. of.Hot Tubs No. of Transformers KVA Above ❑ ❑ of Lighting Fixtures SwimmingPool rnd. rnd. Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of 'Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total No. of Ranges No. of -Air Conditioners Tons Initiating Devices No. of Sounding Devices. Heat Tota I TotaT No. of Disposals No. of Pumps Tons KW No. of Self Contained Detection/Sounding Devices. Municipal ET [:]Other No. of Dishwashers - Space/Area Heating KW No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO O 1 have submitted valid proof of same to this office. YES 0 NO ❑ If you have checked ES, please indicate the type of coverage by checking the appropriate box. INSURANCE I BOND ❑ OTHER❑ (Please Specify) Estimated Value of Electrical Work $ Wprk to Start Signed under the penalties of perjury: FIRM NAME AAlOrt C_ C11 � Inspection Date Requested: Rough Final LIC. NO. Licensee ;"-r H 0,v y ¢ 1,y o& ( Signatu LIC. NO. 19- 0i 3 % S Address VCU (t D 1T F VE n f><is. Tel. No. SV9 -37)- -St 77 Alt. Tel. No. :OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts .General Laws, and that my signature on this permit application waives this requirement.. Owner Agent (Please check one) l Telephone No. PERMIT FEE �3061- r0 (Signature of Owner or Agent) 1✓h (Expiration Date) J.