EP-38816 �. .
TOWN OF DARTMOUTH
3881 6
'*Bt1LDING RECEIPTS
2 �' n C 0 cTORIS OFFICE a
4 AA i tins ut
Name: / Property �'� '
i ,( Date: i � _
/ /• �‘
Job Location: '
Plot Z(` " White Copy-Collectors Office
C � .. Lot - >'�, i' c :=—�Yellow Copy-Customer's Receipt
Pi op File Copy
Phone: _ - �R `3 " Co -Building Department
E c1 1'�
Description
General Ledger#'s 'es — Amount
License&Permits-Building 01000-44105
License&Permits-BuildingMisc. 01000-44105
License&Permits'Electrical ,' 01000-44106 ?�
ea
License&Permits--Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420
This is not a Permit or License for Building,Plumbing or Gas Received By: / — ,
,
Commonwealth. i�nqnq o/t/lamachzueella Official Use Only" ap t
- t ccyy,� a c�77 n(� Permit No. 3 /yrr "
- JJeparlmenl o Jire Serviced ,/
- ,e 6a
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Chec
'', Town of Dartmouth [Rev. 11/99] (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: 41 13 °j
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) )2cteR gdaal) Pe D
Owner or Tenant M)CVvcwi._ B1,Ct1 S`r"r\ Telephone No.1f 1 S—4-cc,
Owner's Address S''PC
Is this permit in conjunction with a building permit? Yes in No (Check Appropriate Box)
Purpose of Building S-TV D ie j RornE Sttof Utility Auuit orization No.
Existing Service 20o Amps 110 /2*) Volts Overhead Undgrd c$ No.of Meters I
New Service Amps ./ Volts Overhead Undgrd I I No.of Meters
Number of Feeders and Ampacity N1 \J (‘N\SS c$ w) j-t) rcB%� ¶kiwi }dui MA113 ik,p 5
Location and Nature of Proposed Electrical Work: ?A9r a '^sm. t Wu),
Completion of thefollowing table may be waived by the Inspector of Wires.
No.of Recessed Fixtures No.of Ceil.Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Lighting Outlets No.of Hot Tubs Generators KVA
No.of Lighting Fixtures - Swimming Pool Above In- No.of Emergency Lighting
gmd. gmd. 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. Tons No.of Alerting Devices
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 Municipal
Connection Other
i No.of Dryers Heating Appliances KW Security Systems:
tt No.of Devices or Equivalent
\+ No.of Water No.of No.of Data Wirin.gq
\ai Heaters KW 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 desired,or as required by the Inspector of Wires.
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 '7 BOND OTHER I I (Specify:) .7 OS
(Exp{ration Date)
Estimated Value of$lectri,cal Work: ' j &p (When required by municipal policy.)
Work to Start: 9j 141 OS Inspections to be requested in acco dance with MEC Rule 10,and upon completion.
I cert , under the pains and penalties ofperjury, that the informatis ' l his application is true and complete.
FIRM NAME: rj�{ldlq '= ,c'�j( ,// - LIC.NO.' `r e21'ajp�,j
Licensee: PA VL SM&A Signature C, LIC.NO. E 213%
(Ijapplicable,enter"exempt"in the license number line.) Bus.Tel.No. i f16b-i t}`7 I' I2a))
Address: 1\ CA)vt1 CT t3ffDVD fl)) IN 0 3l\c' Alt.Tel.No.: 6e 1-i44p9- 30i1,-,{0(.10
OWNER'S INSURANCE WAIVER: 1)am aware that the Licensee does not have the liability insurance covera a normally required by law. By
my signature below,I hereby waive this requirement. I am the(check one) owner H owner's agent
Owner/Agent '/
Signature Telephone No. PERMIT FEE:$ 6oi
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