EP-66584 TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT u t` 0 U -j 3 4
// �. PHONE:/ 508-910.1820 FA . 508-910-1838` 5 /
Nam, ti n 4 J �///2 /�s� operty Owp - ,/,ine "-.r� Date�:�/ `�"�?.,
Job Location: /1 7 /L') t / /�,..'C_ Map: v Lot ✓1 j� �
Description//// General Ledger#'s Ref. # Amount
Building & Building Misc. 01000-44105
Electrical 01000-44106 )/ c_ �<'r 7 U
Plumbing & Gas 01000-44107 lj e,,L
Trench Safety 01000-44129
Other Department Revenue 01000-42420
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White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By r/ j )
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL;PLUMBING OR GAS
, Commonwealth oil/d/adoachuseh Official Use Only
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-ryxr--= cy� c7 Permit No.
_'- - d 3apartment o/..lire.ervicee
-�_ Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C,527 CMR 12.00
(PLEASE PRINT IN INK O PE ALL}INFORMATION) Date: 5 '3/(C.
City or Town of: q rlt-a'^G,-c>A To the Inspector of Wires:
By this application the undersign-egives notice of his or her intention to perform the electrical work described below.--7
Location(Street&Number) / w f206/ L..A
Owner or Tenant I ,ci )<( v \ e'r-i-i- t/Cou Cr Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes n No J (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ri Undgrd No. of Meters
New Service Amps / Volts Overhead I I Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Pao` ' -. S N y
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers
No. of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- - ❑ No..ol Emergency Lighting
untiuntil. grnd. Batten Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
t No. of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
' Heat Pump Number Tons KW No.of Self-Contained
No.of Waste Disposers
Totals: Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KVV Local❑ Municipal Connection ❑ Other
No.of Dryers Heating Appliances ICW Security Systems:*
No.of Devices or Equivalent
No.of Water No.KW No.of No.of Data Wiring:
Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wirin :
No.of Devices or Equivalent
OTHER:
•
Attach additional detail ffdesired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 2_2_0CsCiC) (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof 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 ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: \\n`/-�1 LIC.NO.:
Licensee: o,S P Signaturg ".__C LIC.No.:.50 310 t.
(If applicable,enter tempt' in he licen nvq beee�line.) 1i�� Bus.Tel.No.SOSr7L 6-O(0a0
Address:2iy cQ e .) T to,`t, \C 1 V ate,Irk A- p'2.11 )t Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-61,security work requires 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 j
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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