HomeMy WebLinkAboutMiscellaneous - 85 MARTIN AVENUE 4/30/2018 (3)Commonwealth o f Majdac4ajetb Official Use Only
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Permit No.
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Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFO TION) Date: U ` l A ` or
City or Town of: A ' �-� tri/ To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work escribed below.
Location (Street & Number)y✓-r
Owner or Tenant r F C/�\
Telephone No.
Owner's Address
Is this permit in conjunction mith a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building
Existing Service Amps / Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Utility Authorization No.
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
No. of Meters
No. of Meters
Cmmnletinn of the following table may be waived by the Inspector of Wires.
Attach additional detail tf desired, or as required by the inspector oi wires.
Estimated Value of Electrical Work: A,o - j (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
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 X BOND ❑ OTHER ❑ (Specify:) L, 6e,t-�Y ",ku4
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: Yr,�e,� �� " a ,,,&t En, inern
Sc <-`.; LAs AJ A—L C LIC. NO.: I0/a
Licensee: �E- t^ aver LIC. NO.:
(If applicable, enter "exempt" in the license numer ling.). Bus. Tel. No.:791
Address: e_ TA P a, Mk 0\ C>^ Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Deliartmerif of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
requiredby law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent. PERMIT FEE: $
Signature Telephone No.
No. of Total
No. of Recessed Luminaires
No. of Ceil.-Sus p• (Paddle) Fans .Transformers
KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA .
No. of Luminaires
Above In -o.
Swimming Pool rnd. grnd.
ot Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
of Detection and
No. of Switches
No. of Gas Burners
Initiatin Devices
No. of Ranges
No. of Air Cond. Tons Tot
No., of Alerting Devices
Heat Pump
Number
Tons
K
No. o Self -Contained
No. of Waste Disposers
Totals:
.. ...•
...
•�••�• --***I*-*
................
D-etection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
p g
Local ❑ Municipal . ❑ Other
Connection
No. of Dryers
Y
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water,
No. of No. of
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 tf desired, or as required by the inspector oi wires.
Estimated Value of Electrical Work: A,o - j (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
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 X BOND ❑ OTHER ❑ (Specify:) L, 6e,t-�Y ",ku4
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: Yr,�e,� �� " a ,,,&t En, inern
Sc <-`.; LAs AJ A—L C LIC. NO.: I0/a
Licensee: �E- t^ aver LIC. NO.:
(If applicable, enter "exempt" in the license numer ling.). Bus. Tel. No.:791
Address: e_ TA P a, Mk 0\ C>^ Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Deliartmerif of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
requiredby law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent. PERMIT FEE: $
Signature Telephone No.
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