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Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. �cfAu—
BOARD OF FIRE PREVENTION REGULATIONS Permit Fee Assigned
u,p [Rev. 11/99] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
FOR INSTITUTIONAL* USE ONLY
This forin is for use by institutions employing licensed electricians and others for which notice of electrical installations to the
municipal Inspector of Wires is required for work on the premises of the institution. If you are not an employing institution
pursuant to C. 141 §8 of the Massachusetts General Laws,stop here, You cannot use this form, Use the standard form only.
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: I I
City or Town of. N�\ �A(�Ab Q< To the Inspector of Wires:
By this application the undersigned gives notice of the on-premises performance of electrical w Ic by employees.
Institution
Address au) V\,
Location and Nature of Proposed Electrical Work:
NOTE: C. 143 §3L of the Massachusetts General Laws obliges those who perform electrical installations to give notice of
same to the municipal Inspector of Wires. You may do so by filing this form upon each such occasion, or if so contem-
plated in an annual permit fee schedule set by the municipality you may maintain a contemporaneous log of such work,
which shall be exhibited to the Inspector of Wires during normal business hours without advance notice. Some municipali-
ties may set nominal fees for annual permits and require individual permits for work above a stated magnitude.
We will file this form on each such occasion(check one): YES Fj NO
We will maintain one or more contemporaneous log(s) (check one): YES 5g NO ❑
This option is available where so contemplated by the municipality. In these cases,you must renew this application annually,
and upon significant changes in employment.
The following individual(s)will be responsible for the accuracy of the log(s),if maintained. You agree that the log(s)will be
located as indicated below. The coverage in any individual log must be for contiguous property except by arrangement with
the Inspector of Wires.
Attach sip pplein ntary sheets if required for additional log locations.
Log coverage,and location where it will be maintained Responsible person
V�Aa �I, C\
You may maintain the logs electronically upon agreement with the Inspector of Wires. If you intend to apply for such a proce-
dure,indicate below how the Inspector of Wires should access the log:
How many electricians and/or system technicians(as licensed by the Board of State Examiners of Electricians)do you employ
at your facility? Indicate the total number and also indicate the number of full-time equivalent staff that number includes:
173 Total electrical employment: Full-time equivalent electrical employment:
How many helpers'or apprentices do you employ to assist your licensed staff,under their direct supervision(see c. 141 §8)? In
general,this number must not exceed the ratio of one licensed individual to one-unlicensed individual. Limited exceptions ap-
ply for veterans(see St. 1962, c. 582 §3 as amended by St. 1979, c. 156). Indicate the total number and also indicate the num-
ber of full-time equivalent staff that number includes:
Total electrical employment: Full-time equivalent electrical employment:
Not all electrical work for which notice to the Inspector of Wires is required must be performed by licensed personnel. How
many such persons,not required to be licensed,do you have in your employ? Indicate the total number and also indicate the
number of full-time equivalent staff that number includes:
Total electrical employment: (S� Full-time equivalent electrical employment:
*.Institutions are defined for these purposes as any person,fain, or corporation operating tinder c, 141§8,
(Please see reverse side for certifications and required signature.)
All I'mCOMMONWEALTH OF M limilmalSAG�l��, 5.,:
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FLEE TR1C'tANS
ISSUES T,HE FOLLQW#NG I10ENSE AS..A
REGISTEAED MASTER; ELECTRICIAN
L. ZA E.LECTR t C ?,
15 JOD L:
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AMPST'EAD NH 03841-2188
11943 A 07l31/16; 48642