EP-28664 r-c-rfeA T P . edyter ce TOWN OF DARTMOUTH
itai p 11-f=f1L-C1 r`lLl4 BUILDING RECEIPTS -
COLLECTOR'SOFFICE -
Name `,1.,. Property a. Date , ..,
Owner: 1 t G J
Job Locafion: ; :y ! 1.1?
° C White Copy-Collectors Office
_ Yellow Copy-Customers Receipt
Plot: .%; Lot i ! _ 2 i003 Pink Copy-File Copy ;
ty - Green Copy-Building Department
Phone
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Description General Ledger#'s Ref.# i Amount
License&Permits-Building 01000-44105
License&Permits Building Misc.- 01000-44105,-
License&Permits-Electrical 01000-44106
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420 -
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This is not a fornon TeitsOtr rtrg,$1rurnR or Gas Received By:
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The Commonwealth of Massachusetts R Office
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\C--.4e BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1Z00 ACT
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed In accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK o4IPE All INFORMATION) Date S / 7vv3
City or Town of 0 AleTLZ/DLinid To the Inspector Wires:
The undersigned applies for a permit to perform the electrical work described below. lr/,I 77
Location (Street E. Number) -9 J'Z, Crites Drt4 4y - WIV� / L' ) , ,
Owner or Tenant 20_407, peen F/�,41 /
Owner's Address 38U M 0,v7.39 up. Sr. argi, M y.c,c
Is this permit in conjunction with a building permit: Yes Vy No ❑ (Check Appropriate Box)
Purpose of Building PiEtt/ Nj1/2./1 Utility Authorization NO.
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters
New Service 'Lop Amps /7:o I�2.yO Volts Overhead CI .Undgrd, No. of Meters
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Number of Feeders and Ampacity O ,Z&,py . I /Pa.
Location and Nature of Proposed Electrical Work
2/C4t/ /4R4)4
No. of Lighting Outlets No. of Hot Iubs No. of Transformers Total
ICVA
No. of Lighting Fixtures SwimmingPool Above In-
grnd. ❑ grnd. ❑ Generators KVA
No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting
4 Battery Units
No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones
Total No. of Detection and
4No. of Ranges No. of Air Cond. tons Initiating Devices
Heat Total Total I
No. of Disposals No, of puyrtps Tons KW No. of Sounding Devices
No. of Dishwashers Space/Area Heating KW No. of Self Contained
Detection/Sounding Devices _
No. of Dryers Heating Devices KW Local EllMunicipal ❑Other
Connection
No. of Water Heaters KW No, of No. of Low Voltage
Signs Ballasts Wiring
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial
equivalent. YESO NO I have submitted valid proof of same to this office. YES❑ NO
If you have checked YE', please indicate the type of coverage by checking the appropriate box.
INSURANCE ❑ BOND OTHER ❑ (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work S
Work to Start Inspection Date Requested: Rough Final
Signed under the penalties of perjury:
FIRM NAME LIC. WI__
Licensee / 4 jS P/?�E',,/,,�', Signature // LIC. NO.33s 5/5'E
Address //ai7 22.5E S']'-7 A.l.Q. zicts� Bus. Tel. No.
Alt. Tel. No.‘67)8 4pr its s/9S
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
stant nt as required en Massachusetts General Laws, and that my signature on this permit
app7 ati n w s th 11 requi=yment. Purer Agent (P'glease checck one)
�,f/tit�,, Telephone No. Sv y!6 JUC/Z^ PERMIT FEE $
Signature of Purer or Agent)
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