EP-88183 TOWN OF DARTMOUTH -tt1ED144G DEPARTMENT RECEIPT 3 3 - 3
PHONE: 508-910-1820 FAX: 508-910-1838
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Nam . , ,Ja, c Property Owner: c1 /t/4 t ,„- s. iDat /2// j
Job Location:M - ' g1 9-(„4",f.,../t- i- v3+°� id nap: 6 th:5
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Description General Ledger#'s Ref # € Amount
Byliding &puilding Misc. 01000-44105afr,
o1dQFp
/Electrical 01000-44106
Plumbing as 01000-44107 A/49
rench01000-44129 �87p
Other Department Revenue 01000-42420 ���y /
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While-Collectors Office Yellow Copy-Customer's Receipt Pink Copy-Budding Department Receive ✓Vteet"--
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
QQ'' q� /
Commonwealth al/IJaeaachuaeZ`fs Official Use Only
.„ * ccyy Permit No.
� _ *� — � 1JePartmant el 3ira�eruicef .
`_49 BOARD OF FIRE PREVENTION REGULATIONS Occupancy. 10 ] and Fee la Checked y•�"vy.,o [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: 142ycc li 2? 2c/57
City or Town of: ]59 ,,t-}-n To the Inspector of Wires:
By this application the undersigned gives1� r notice of hisI orI her intention to perform the electrical work described below.
Location(Street&Number) 3o j —r✓Iavtrit )- rrf >^f ,i I o
Owner or Tenant 49,55, 5 )US Telephone No. 7711 190 251/Y
Owner's Address / 79 m-c
Is this permit in cp
conjunctionQt:with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building h 5 y c �%'4 i Utility Authorization No.
Existing Service 2e:R_.> Amps �k / Z9a Volts Overhead WI Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Mete tr
Number of Feeders and Ampacity - °
Location and Nature of ProposedJ Electricalli Work: fir/)�-c 5,zy cLsq.,3e 6cro .,. CY1 C4Ge-Gg�e
mc-
Completion of the following table may be we- ed by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Trans T TVA
form:�s KVA
No.of Luminaire Outlets No.of Hot Tubs Generate s KVA
No.of Luminaires Swimming Pool Above ❑ In- m No.of E a ergency Lighting
grnd. grnd. m Batte nits
.. No.of Receptacle Outlets No.of Oil Burners ',FI' 'ALARMS No.of Zones
No.of Switches No. of Gas BurnersNo. Detection and
- 1 .._ nitrating Devices
' No. of Ranges No.of Air Cond. Total .of AlertingDevices
Tons
Heat Pump Number Tons: KW o.of Self-Contained No.of Waste Disposers
Totals: Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KW - Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances EM, Securi No o yf Devices or Equivalent
No.of Water Heaters KW No.of No.of Data Wiring:
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 desireci or as required by the Inspector of Wires.
Estimated Value 9f Electrical Work: Y,rjc7, ca (When required by municipal policy.)
Work to Start: J9/ 'y/l`f 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 igl BOND 0 OTHER ❑ (Specify:)
I certify,under the p ins and pena lties of perjury,that the information on this application is true and complete.
FIRM NAME: e Ir"llrrLin_ - 1cc7r'y� LIC.NO.:
lc.ii 91 .
\\p�er
Licensee: 1 `yip Signature " LIC.NO.:%Wiper
(If applicable,enter,,`e �mpt"in the license number tiny.) Bus.TeL No.:-'Y212 )5)3
Address:)fol )eijc'. H,•I( lic` kbe,,r1-. 10 a2 a 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 0 owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
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