EP-53382! --,::,
`.� TOWN OF DARTMOUTH ti.
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`, ,} „1- BUILDING RECEIPTS ; ,;t
` ; COLLECTOR'S OFFICE
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Name: _ Property c- , - Date: ,
_ Owner: �-) (' e -C. % l -i s'
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Job Location:
zr r White Copy Collectospffice
Yellow Copy Customer Receipt
Plot: j Lot: ) > /' tr _--Pm1 C py File C9��ggy
/` --y. ,-GrgenCopy Btiding Department
Phone: - -
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Description General Ledger#'s Ref.# � —R`Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106 „` 4f .,7 y
-7 c-
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420
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This is not a Permit or License for Building,Plumbing or Gas Received By: - -- 77' = -`-
Office Use Only
The Commonwealth of Massachu• setts 5 3�2�� ... ,. Permit To.
a : Depamncnt of Public Safety ¢}_
- � Occupancy L fee Checked fy 7D BOARD OF FIRE PREVENTION REGULATIONS 527 CMR TLC° 3/90 (lean blank)
APPLICATION FOR PERMIT TO PERFORM. ELECTRICAL WORK
All.wk to be performed In accordance with the Massachusetts Electrical Cods.527 CMR I2150 hi/
(pincE PRINT IN INK OR TYPE ALL INFORMATION) Date b%// cr
City or Town of ALAocte nin v7N To the Inspector of irese�
The undersigned applies for a permit to perform the electrical work described below:
\\ Location (Street & Numbe{}/'dun Ft e (�/jn 9. 2r, pi e ,
V
r or Tenant /i rose rh eh, aAin( C)WV? e 2
r's Address aS 0�GYJ�e /',rIhis permit in conjunction with a building permit: Yes ❑ No (Check Appropriate Box)
\ ose of Building ��S)tie y)T/, Utility Authorization NO.
/ Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters
New Service Amps / Volts Overhead I1 Undgrd❑ No. of Meters
Number of Feeders and Ampacity
location and Nature of Proposed Electrical Work
ki r G.I.
No. of Lighting Outlets No. of Hot Tubs No. of Transformers orAal
RV
No. of Lighting Fixtures - Above In-
Scrymming Poo
grnd_ grnd. LJ fGenerators KVA
No. of Receptacle Outlets No. of Oil Burners (NO.fe onV Unitsf Emergency Lighting
Bat
No. of Switch Outlets No. of Gas Burners 'FIRE ALARMS No. of Zones
No. of Ranges INo. of Air Cond. Total Initiating Devices
No. of Disposals No. of Heat Total Iotal
Pumps Tons KW No. of Sounding Devices
No. of Dishwashers Space/Area Heating KW No. of Self Contained
Detection/Sounding Devices
No. of Dryers Heating Devices KW Local O Conneicction Munipal Other
No. of
irin¢
No of Water Heaters KW Sign-osf Ballasts lWWow Voltage
No. Hydro Massage Tubs No. of Motors Total HP i
Na I1 $er Wonc in to I v cit. te ,-.,`i / J R;mr i`—
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I bave.a current L- bility Insurance Policy including Completed Operations Coverage or its substantial
equivalent. YES NOD I have submitted valid proof of same to this office. WEB- NO E]
If you have checked YES, please indicate the type of coverage by checking the appropriate box.Cx.
INSURANCE PrBOND 0 OrER 9 (Please Specify) �/e )9err//h f .717 S CQ_ p/�-6/C t-
Estimated Value of Electrical Work S (Expiration Date
1of�[7A
Work to Start ftn y72ryjp Inspection Date Requested: Rough _Final 6(hre NIAti
)Signed under the penalties of perjury:
FIRM NAME/Azy.///P( /1/.FdgU e ,( -1ST"' y
TIC. NO.r2y, 'F 7 ,-
l icensee
rCcr, .ice Signature /� A�1� a/cr4'.+rg LIC- NO-Sa 47
Address 52tc..c i rJ).'/7/ 6 T , fI7 C. pit/e e maus_ Tel. 17o.606-,-4.63 _S'F+ 'j )
lt. Tel_ No.
OWNER'S INSURANCE WAIVER:
I am aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent n (Please check one)
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Telephone No. PERMIT FEES 5
(Signature of Owner or Agent)
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