HomeMy WebLinkAboutWiring Permit - Permits #12726-1 - 294 CHESTNUT STREET 9/24/2015 _ Date..
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""'•••ELECTRIOAL INSPECTORC12Ck#
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BOARD OF FIRE PREVENTION REGULATIONS [Rev- 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code-Iq, 527 LuCNM 12.00
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(PLEA SE PRINT TN MK OR TYPE ALLINFORMA HON) D ate: M
City or Town of .N(J�M AW, A)a To the Inspector of Wires:
By this application the undersigned lives notice of his or her inters to perform the electrical work described below_
Location (Street & Number)
Owner or Tenant Telephone No. -
Owner's Address
Is this permit in conjunction with a building permit? Yes F-1 IN o [j] (Check Appropriate Box)
Purpose of Building U-tihity Authorizzation No.
Existing Service Amps l Volts Overhead ❑ Undgrd ❑ No, of Meters
New Service Amps Volts Overhead ❑ U.dgd ❑ No. of Meters
Numbler of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
J
Completion of thefiollowing table may be waived by the Inspector qf'Wires.
No. of Recessed Luminaires No- of Ceil.-Susp- (Paddle)Fans o. of I o a'
Transformers KVA
No. of Lurninaire Outlets No. of Hot Tubs Generators KVA
No. of Luminaires Swimming Pool Above ❑ In- Q
g -No ot V mergency Lighting rnd. grnd. Ba"
1� tteEy Units
No. of Receptacle Outlets No. of Oil Burners FIRE ALARIVIS, No. of Zones
No. of Detection and
No. of Switches No. of Gas Burners
The Commonwealth of Massachusetts
.Department of IndustrialAccidents
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`� t#' Office of.investigations
r r 600 Washington Street
4= Boston MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anylicant Information Please Print Lggibly
Name (Business/Organization/ ndividual): a
Address: t
City/State/Zip:
I Phone #: 1
Are you an employer? Cbec he appropriate box. Type of project (required):
1. 1 am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet_ 7. E] Remodeling
ship avid have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' camp. insurance comp. insurance.
required.]
S. [� We are a corporation and its 10.aElectrical repairs or additions
3.❑ I requ qu a homeowner doing all work officers have exercised their l 1.[] Plumbing repairs or additions
myself (No workers' camp. right of exemption per MGL 12.0 Roof repairs
insurance required.] �' c. 152, §1(4}, and we have no
employees. [No workers' I3.[ Other
comp. insurance required.]
*Any applicant that checks box#I roust also fill out the section below snowing their workers'compensation policy information.
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