EP-76219 TOWN OF DARTMOUTH - BUILDING DEPART E k219
PHONE: 508-910-1820Or FAX:,�508-9
,.Name: / � P op/�rty Owner: �� �4' i Date: 'f
/'
Job Location: f r��' >/ d„�--t�'� %\. l? ti Map: lL' Lot: /
Description General Ledger#'s Ref. # Amount
Building&Building Misc. 01000-44105
Electrical 01000-44106 571-ULi7 v. l -i
Plumbing& Gas `'0C1/ (l 7
:.<, Ty
Trench Safety 01000-4412
Other Department Revenue !"$1ldb0�4242(
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7. ! , 2
White-Collectors Office Yellow Co )) ``py-Customer's Receipt Pmk Copy`�Bwtdmg Department RCCCIVed B}' .j` t✓z%
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
- CommonweaUh of rrladdacLoett6 Official Use Only
- ��77 Permit No.
'. - ni 5 rt • 2eoartment o/._Yire Serviced • - -
--_11-,I - - Occupancy and Fee Checked
"\r,0 BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEG'),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: /-b - a o l$"
City or Town of: l7Arcl-trtok444 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) 132,1 REED S}-
Owner or Tenant C`nee-1I c . &J< eNt1 /CA Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes u No ❑ (Check Appropriate Box)
Purpose of Building f)t -e I(i A/S L{,ai rf Uti sty Authorization No.
Existing Service Z4)0 Amps I zo /Zit o Volts Overhead Undgrd
g �❑-I No.of Meters I
New Service Amps / Volts Overhead❑ Undgrd I 1 No.of Meters
Number of Feeders and Ampacity wf u Al;
Location and Nature of Proposed Electrical Work: 1 5eh+70.v 'fkf\ /
Completion of the followin• table may be waived by the Inspector of Wires.
No,of Total
No.of Recessed Luminaires 14 No.of Ceil:Susp.(Paddle)Fans 1 Transformers KVA
No.of Luminaire Outlets I No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting
grnd. grnd. Battery Units
No.of Receptacle Outlets S No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches b No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. .TL°ons No.of Alerting Devices
Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers
Totals: _ . Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local 0 Municinectipalon El Other
Con
No.of Dryers Heating Appliances , Security Systems:*
No.of Devices or Equivalent
No.of Water KW
Heaters Signs Ballasts No.of Devices
of No.of Data Wiring:
evices 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 pitWires.
Estimated Value of Electrical Work: I oo °o (When required by municipal policy.)
Work to Start: /-b- Z0/y 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 0 OTHER 0 (Specify:)
I certify,under the pains and enalties of perjury,Ltthat the information on this application is true and complete
FIRM NAME >ro-X heSseIt( 'lcctoic, - LIC.NO.r 30t19 L-_
Licensee: .5tel/ Re5(Site Signature LIC.NO.:
(If applicable,enter "exempt"in the lice se number line.) Bus.Tel.No.,3 Pb-Via'i 0.63
Address: 571- KN SI �u tt ur7y DIZb7
�j Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-6I,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)0 owner ❑owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
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