EP-59616 n, TOWN OF DARTMOUTH
\k,..:'*- ) .a IthING RECEIPTS
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PHONE: 508.91 18Z F W -1 8 5 9 6 6
Name: , Property Date:I. l {{ (j, /{— / ''
i� Owner: / A<, /'/ / g"lt+ �/ /!1'�
Job Location: r..� ,y n„,y�, /' lea ' _„_..,, y-white Copy-Collector's Office
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7/"__ r.'--,r., ✓ Pink Copy-File Copy
Map: ,� � Lot Green Copy-Building Department
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Phone:
Description General Ledger#'s Ref. # Amount
License & Permits - Building 01000-44105
License & Permits -Building Misc. 01000-44105
License & Permits- Electrical f. 01000-44106 , j ----
3
License & Permits-=Phtmb ng & 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: 717C A 7 r /t,-'
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ammonium&of//(amaslaw fd Official Use Only /
ttyy� cC77 �l Permit No. �t°�
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BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1 Occupancyand Fee Checked
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR ,
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: a-1C
City or Town of; 130 ' r rinni c+F To the Inspector of Wires: k .
By this application the undersigned gives notice of his or her intention to perform the electrical work escribed bel v.
Location(Street&Number) IV. '1 ‘...o v-e-V--5 LC 1-e_ I 3 Lp 4g
Owner orTenant -- itt_rT . .7-Lt°(y17og-v- Telephone on 2 Z
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropri e Box)
Purpose of Building Utility Authorization No.
Existing Service Amps • / Volts Overhead❑ Undgrd® No.of Meters
New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Install low voltage security systems •
Completion of thefollowingtable may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires SwimmingPool Above ❑ In- ❑ No.or Emergency Lighting
grrnd. gird. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Detection and
No.of Switches No.of Gas Burners Initiating Devices
No.of Ranges No.of Air Cond. Toms Tons o
No.
f AlertingDevices
No.of Waste Dis osers Heat Pump Number Tons __1 KW No.of Self-Contained
p Totals: — 1"V Detection/Alerting?evices
No.of Dishwashers • Space/Area Heating KW Local Monunicjellne ial on ❑ der
C
No.of Dryers Heating Appliances KW Security Systems:" 1
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs lquzarf Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER: .
Attach additional detail ifdestred,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (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 0 (Specify:)
I cert(J),under the pains and penalties ofperJary,that the information on this application is true and complete.
FIRM NAME: BROADVIEW SECURITY MC.NO.:1799 D
Licensee: David Holton Signature I)08.-2 ilttua LIC.NO.: 7067C
(Ifapplicable,enter exempt"in the license number line.) Bus.Tel.No:401-333-9425
4 Address: 24 Albion Rd,,Lincoln,RI 02865 Alt.Tel.No.:
'y °Per M.G.L.c. 147,s:57-61,security work requires Department of Public Safety"S"License: Lic.No. SSC01163
\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)0 owner B owner's agent.
Owner/Agent
Signature . Telephone No. ( PERMIT FEE:$ n5,
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