EP-40851 TOWN PF DARTMOUTH 51
BUILDING RECEIPTS
COLLECTOR'S OFFICE
Name: - ' Property - , Date: - I / / `` _.y}i ! / / Owner: . __+L-i ---'` `=: % JF✓/ /
Job Location: J y
Whi e C y-Collectors Office
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Plot: -�, I Lot: jam, ) ".7. .yII/tt_ -Yell C y-Customer's Receipt
/C t J j ,_,.„,,,Pink op -Eile Copy
itt—I. f ialrdrf- Co -Building Department
Phone T
NO TA)( Issues
11I1/i ^_it A J 13
Description General Ledger#'s 'ef.# -. Amount
License&Permits-Building 01000-44105,
License&Permits-B`uilding r iec: 01000-44105
License&Permit$`-Electrical f 01000-44106 r it,. i II
- ,
License&Permit`s,-Plumbing&Gas 01000-44107 r "r V
Other Department Revenue 01000-42420 /
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This is not a Permit or License for Building,Plumbing or Gas Received By - ";;N- >%:7 v -l_+ .
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Commonwealth, /fleacheta Official Use Only'S 'j
Permit No.e •�t 1epartmenl o/Jere Sericea
e �' )A /
A4 ' BOARD OF FIRE PREVENTION REGULATIONSy/' Occupancy and Fee Checked
's ,a 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: ^ 1 S -O 5
By this application the undersigned ives notice of his or her' tention to perform the electrical work described below.
Location(Street&Number 2;;de —
Owner or Tenant e Telephone No. / 711!" 1 /o /
Owner's Address 7-R' fYl; 1{e IS -e-
Is this permit in conjunction with-a building permit? Yes No I.1 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead I I Undgrd I I No. of Meters
New Service Amps / Volts Overhead I I Undgrd I I No.of Meters
Number of Feeders and Ampacity ,
Location and Nature of Proposed Electrical Work: i vi (;e r;in 4._ n
Completion of the following 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 grade In-
No.o Uis Emergency Lighting
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 fi Municipal I I
Connection I Other
ct
" No.of Dryers Heating Appliances KW Security Systems:
No.of Devices or Equivalent .
"at
No.of Water No.of No.of Data Wiring:
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, has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND I I OTHER I I (Specify:)
? (Expiration Date)
Estimated Value of Electgcal Work: I 5 C) (When required by municipal policy.)
'-Work to Start: /S -OS /Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I certi[y, under the pains andnal4es of perjury, that the information on this application is true and complete. _
FIRM NAME: STc Uc i'N Noce, i-0.- LIC.NO. i 0 .2 .2-�'� e.
Licensee: Cfir uCr. Zr Per et in Signature -��ri7��-i'/Vt,t,l---.._ LIC.NO. in SS G'-R
(If applicable,enter"exempt"in the license number line) Bus.Tel.No.: c G) i// C
Address: t(aS 3+eoenr gt Swinseat /YIP • O"2.771 Alt.Tel.No.: 4146 327X
OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the liability insurance covera a normally required by law. By
my signature b I hereby wave this requirement. I am the(check one) I I owner I owner's agent
. Owner/At / 7c.� �� .
Signature Telephone No. 5Ot7i7- jJ /,ERMITFEE: $ (C?�"�
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