EP-59297 T
v , ' p- .= TOWN OF DARTMOUTH
4' 1,3 ' ) zi e- BUILDING RECEIPTS TOWN OF DARTMOUTH
°`- L i PHONE 508.910-1820 FAX: 508-910.1838 Gnl I FrT(1R,4(1FFISrg L..3 7
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Name:- •/} / ] / / Property r d / �� // )
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Job Location: 11 t - > White Copy-Collector's Office
it/ /f // ^ f'I / e�_, Yellow Copy-Customer's Receipt
--_ --. PinkCopy-FileCopy
/ < Green Copy-Building Department
Map: �Afr (/ Lot: i .i -:..-�1of( )
Phone:
Description General Ledger#'s Ref. # Amount
License &Permits - Building 01000-44105
License & Permits - Building Misc. 01000-44105 '
i
License &Permits - Electrical 01000-44106 /1 / f� !/ ( '.
License & Permits -Plumbing & Gas 01000-44107 /
License & Permits - Trench Safety 01000-44129
Other Department Revenue 01000-42420
THIS IS NOT A PERMIT OR LICENSE FOR BUILDING, PLUMBING OR GAS
Received By:
Con:monwea&al rrla!lackt effd Official Use Only
n Ci ccyy� c�77 nn Permit No.
pE ��r. - t 2eparimenf al give Jerviced
._t(_ d` Occupancy and Fee Checked
"= -e BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 3 —1-10
City or Town of: ,naninOt A- To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) I? (A/r /rem Lana
Owner or Tenant 60 adeenMori Telephone No.
1 Owner's Address
Is this permit in conjunction with a building permit? Yes Er No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd❑" No.of Meters
New Service 0100 Amps 1aa /340 Volts Overhead in Undgrd F 4 No.of Meters i
Number of Feeders and Ampacity
i.
Location and Nature of Proposed Electrical Work: (Here llebv name w/ao o4 0,6, cSef ice
Completion of the following table may be waived by the Inspector of Wires.
t No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No. Total
_ Transformers KVA
. No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires SwimmingAbove In- No.of Emergency Lighting
Pool grnd. ❑ grnd. ❑ Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: --' '-'''''' Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ M
Connectio°mcipaln ❑ Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water , No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring
No.of Devices or Equivalent
OTHER:
Attach additional detail if desireol or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 3 —1-10 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
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undersigned certifies that such covee is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE Q BOND 0 OTHER ❑ (Specify:)
ti ils, I certify,under the pains and penalties of perjury,that the information on this application is true and complete. f
FIRM NAME: Z-4So✓l 2O14 Ller . LIC.NO.: 2c)1GS—
Licensee: Signature LIC.NO.:
(If applicable,enter "exempt"in the!tc nse number line.) I Bus.Tel.No.• Sob'- t9-6-"4'6 7
Address: SW Ye/la c L'f Af, !I/- Qo Ahtu,,,itr n PI I'ia-7 t+7 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
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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