EP-2743 < - -- - TOWN OF DARTMOUTH 02743
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N O TAX ISSUE *BUILDING RECEIPTS
OLLECECTOR'S OFFICE.
Name: - - / Property Date:
Owner: _mac.. /
Job Location: t' r'
L.- White Copy-Collector s Office
Plot: Lot: .. s. Yellow Copy-Customers Receipt
Oc Pink Copy-File Copy
- Green Copy-Building Department
Phone:
Description General Ledger#'s r Ref.# Amount
TOWN OF DARTMOUTH
License&Permits-Building 01000-44105 -A(COLLECTOR'S OFFICE
License&Permits-Building Misc. 01000-44105 Jut. i a 199/
License&Permits--Electrical 01000-44106 A
License&Permits-Plumbing&Gas 01000-44107 S 5`
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Other Department Revenue 01000-42420Q��
This is not a Permit or License for Building.Plumbing or Gas Received By: , ._
Office Use Only � +.
\ The Commonwealth of Massachusetts Permit No. a 7N
Occupancy & Fee Checked c n/ . .1_Cr
Department of Public Safety Nave blank) 7_74c -
7r�
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 .
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
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All work to be performed in accordance with the Massachusetts Electrical Code. 527 CMR 12:(X)
( PLEASE PRINT IN INK OR TYPE ALL INI:ORMA'noN ) I);t q tc ri - / ? — ` i •
The undersigned applies for a permit to perform the electrical work described below. 0�
Location (Street R 17
Number) 6_--. _O._(_e_Fine.____-D Ie'_.
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�or Tenant -��CY� {LO (�C1 __- pL /7
Owner's Address ___(2 .6_0._/CL Ft n d A D Ce�__ __ 1 O • l �__ . _h_1- !O. [.( _j-17
Is this permit in conjunction with a building permit rr
Yes I__1 No F l (Check Appropriate I3ox)
Purpose of Building _ _...__._... _ _ Utility Authorization No ......._.._.. ..____.-__
Existing Service a Q___Amps.--_L / ip1--C Volts *ViaV'Overhead 1__1 Unclgrd II No. of Mcters_„ _'„_.
New Service ... ...__.Amps / .Volts (')vrrhrad n ttnd)pd I I No. of Meters_....:.__.. _-..
Number of Feeder:;and Ampacity _... ............ .._ ........_. / ....___.._......_ .. .. __..__.. ...__._. . ..-_....._..... ........-_____.
Location and Nature of Proposed posed Electrical Work . 6_. Q._I.cLE- fJ 4 __ J` h_Cr—
W 1 . __ o c� /
of Hot Tubs __----- -----_-_�--- -_ Total
No. of Lighting Outlets No.
•No. of Transformers KVA
No. of Lighting Fixtures Swimming Pool nnd`e X girind- Generators • KVA
No. of Receptacle Outlets No. of Oil Burners No, of Emergency Lighting
Battery Units
No. of Switch Outlets No. of Gas Burners FIRE ALARMS NO. of Zones
No. of Ranges No. of Air Cond. Total No. of Detection and
Eons Initiating Devices
Heat Total Total of Sounding
No. of Disposals No. of Pumps Tons KW No. g Devices
No. of Dishwashers Space/Area Heating KW No. of Self Contained
Detection/Sounding Devices
No. of Dryers Heating Devices KW Local — Municipal n Other
Connection
No. of Water Heaters KW No. of No. of Low Voltage
Signs Ballasts . Wiring
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
a
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Polic •includi,n ,Completed Operations Coverage or its substantial equivalent. YES ❑NO,' I have submitted
vallid proof of same to this officer YES'U NO XI If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE ❑'BOND ❑ OTHER 0 (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work S
Work to Start 17- / 6? -9'I Inspection Date Requested: Rough Final (A)// ( CIO //
Signed under the penalties of perjury:
FIRM NAME I IC. NO.
Licensee I ed a I n'y ZoSrl{ Sign:turc .�a+ es- 1J L .
L1C. NO. 3,,P/6,5—
Bus. Tel. No. t
Address _ ,/� _�f I / . T Qi/-44Ifc/ /Ito 0.,2`7/ Alt. Tel. No. 9'7 3`y 602-3- I'':
OWNER'S INSURANCE WAIVER: I am aware that.the Licensee does not have the insurance coverage or its substantial equivalent as required by .Jl.
Massa errs Genera "s, and that my signature on this permit application waives this requirement. Owner Agent (Please check one)
. tpna me t"i r"iu r ernht Telephone No. 99 � � 9
9 i PERMIT FEE S
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•Commonwealth of Massachusetts
.Division of Registration
• Board of Electrical Examiners
026,48-5030
DMI 10 1 COSTA
53 A1111• STREET
ID1
ill . I111111111 111 02719
...
JOURIITNA/1 BLECTRIC111
131165 07/31/91 110727
License No. Expiration Date SeriarNo.
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