EP-59483 i. ) TOWN OF DARTMOUTH
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yx BUILDING RECEIPTS p
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PYi(7N� 508.910-1829 FAX 508.910.1838 C��i �T��q(1,cr F 0 9 8
MAR 25 2� ?
61
Name I Property Date:
" a ( ,1j e_f;( /f l 7 , __... 'ner: _ F Af ,-74:ef.1 J N M O,4o-// 2/O
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Job Location: forl? „f White Copy-Collector's Office
/ f i/; I Yellow Copy-Customer's Receipt
:` I IJ t i l r_ f aPink Copy-File Copy
Map: / Lot: r Green Copy-Building Department
Phone:
Description General Ledger#'s Ref. # Amount
License & Permits - Building 01000-44105
License &Permits -Building Misc. 01000-44105
License & Permits electrical ) 01000-44106 7 r — --
License & Permit&Pluglbirrg& 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: c`/{,y yrl..e"V•-,-
Commonwealth of Massachusetts Official Use Only
443
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W �i- a Department of Fire Services Permit
Mill_ Occupancy and Fee Checked ��
V BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
)N APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.01-
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: `�—c—
'%% City or Town of: 2 , �,C T'flcm IQ, To the Inspector of Wi,. s:
By this application the undersigned gives notice^ of his or her intention to perform the electrical wor escribed below.
I
Location(Street&Number) 1 W 4 ne
Owner or Tenant to`► (—NC U p T. ephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ N' . BL 1 PERMIT#
Purpose of Building Utility A thori;.tion No.
• Existing Service Amps / Volts Overhead n , di d n No. of Meters
" New Service Amps / Volts Overhead ❑ .grd ❑ No. of Meters
Number of Feeders and Ampacity
` Location and Nature of Proposed Electrical Work: Install low voltage security system at above location
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Tf T
Transformers KVA
No. of Luminaire Outlets No. of Hot Tubs Generators KVA
No. of Luminaires SwimmingAbove In- No.of Emergency Lighting
Pool grnd. 1-1 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.o f AlertingDevices
Tons
No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: Detection/Alerting Devices
Municipal
No. of Dishwashers Space/Area Heating KW Local❑ M. -e. a Other
Appliances KW
No.of Dryers Heatingurity Systems:*
No.of Devices or Equivalent I
No. of Water No. of No.of ing;
Heaters KW Signs Ballasts No.o Devices or Equivalent
No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, 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 ❑ (Specify:)
I certify, under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: Brinks Home Security LIC.NO.: 7067C
A
Licensee: David Holton Signature O ,gU.e,. LIC.NO.: SS CO 001352
t (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.: 401-333-9425
\Address: 24 Albion Road, Suite 330 Lincoln,RI 02865 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: $1 S
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