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C..ommonwea& o f Mamac4um L�INOfficial Use Only
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partment of Sire Semicee Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] 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 T PEL I FORMATION) Date: 3-1 I - 1 J..City or Town of: N&t� 1'�0()QC- To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 47,3
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes -9 No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity .
Location and Nature of Proposed Electrical Work: ei.0 AltrtA I P.,Mnt ne n.n ►., a�-
Comnletinn nfthv fnllnwino tnhlo mnv ho wnivod h„ t! o 1--t— nirW;—
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- E]
rnd. grnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
P
HeatPumpNumber.
Tons
KW...........
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 Kms,
Heaters
No. of No. of
Si ns 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.
Estimated Value of Electrical Work: 37W-16 (When required by municipal policy.)
Work to Start: 3000, Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by thetowner, no permit for the performance of electrical work may issue unless
the licensee providesproof 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 El(Specify:)
1 certify, under theains and peva ties of perjury, that the informatio t application is true and complete.
FIRM NAME: V IC m IC. NO.: A;7�
Licensee: Signature LIC. NO.:
(Ifapplicable, enter " empt" in the license,�ber line Bus. Tel. No.:!M �07 5999
Address: Yc�4 �'f ff4 ®j %1/6 Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requirel Department 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
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: $
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