EP-35842 TOWN - OF DART(MIOUTH /p
BUILDING RECEIPTS I
7 ! COLLECTOR'S OFFICE '-� ; _
.a Yk. - max% ..7 f 7n,�`
` f i / ; :-
Name: % a.t✓i Ut. / 6 Property
A &i .,*' _.r. Date: / _`-. 6,.•
Owner:
Job Location: . ,% ! i i _ ,
�/''j� /�{y � � �f L ,�'� n • Y - TQWN OF C6-'. ._OJTN '
1 ,r F /�/� "- con rrrnP s !CE
White Copy-Collector's Office
/ t l , '"�� Yellow Copy-Customer's Receipt
Plot: '�/ V Lot: nu Pit k Co File Co
!! .i� C_D . i Copy Copy
Grren Copy-Building Department
Phone: _ t,
LR11
Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105 r---
License&Permits-Building Misc. 01000-44105 .7 \
License Sr Permits-Electrical 01000-44106 de/f-C � ,.j iffy 07 /
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420 1'
j '$
This is not a Permit or License for Building.Plumbing or Gas Received By:
LOffice Use Only
—_—_ The Commonwealth of Massachusetts S"6tr.)—
,
— if Peraic No.
— _ ' Department of Public Safety
— • BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 3/90 Occupancy a Fee blank `-J L'
AV,, ' (leave Blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed In accordance with the Massachusetts Electrical Code. S27 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 5�/�,
City or Town of ' i �61-1-74- To the Inspector of Wires: r�
/> J
The undersigned applies for a perch to perform the electrical work described below. " � ��
/'
Location (Street A Number) ' 4 A ///�i�S s �fZ
Owner or Tenant `R'CC(�y/rfe B// 15 bs�'
Owner's Address %�'JJ /14////f5 .Pc</(47
J
Is this permit in conjunction with a building permit: Yes ❑ No (Check App ( �x)
7
Purpose of Building 1,(///Il 4 i G20 pG ,Q wb Utility Authorization NO. 44a iss' a15 i3
Existing Service Amps / Volts Overhead ❑ Undgrd El No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd❑ No. of Peters_
Number of Feeders and Ampacity
location and Nature of Proposed Electrical Work 9. Al///'f 9,r/,..0
',I No. of Lighting Outlets No. of Hot Tubs No. of Iransformers Total
RVA
No. of Lighting Fixtures Swimming Pool Abov n-
grnde. grnd. ❑ 'Generators KVA
No. of Receptacle Outlets No. of Oil Burners (Not.te ofryU Emergenitsncy Lighting
Ba
- - _ -No. of Switch 0•_tleti __ _
No. of Gas Burners FIRE ALARMS No. of Zones
No. of Ranges 'No. of Air Cond. Total INo, of Detection and
tons Initiating Devices
No. of Disposals No. of Heat Total Total
PCPs Tons KW No. of Sounding Devices
No. of Dishwashers Space/Area Heating gW No. of Self Contained
Detection/Sounding Devices
No. of Dryers (Heating Devices KW Local❑ Municipal Other
No, oNo. of Connection
No. of Water Heaters Signs Ballasts 1Wl.rin¢ltage
No. Hydro Massage Tubs No. of Motors Total HP I
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 E I have submitted valid proof of same to this office. YESO NO 0
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INELIRANCED BOND 0 OTER J (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work S f ,,,/
Work to Start Inspection Date Requested: Rough �/// CsY/// Final
Signed under the penalties of perjury: I
FIRM NAME LIC. No. t
Licensee J t_ 24 jj Signature t 'i½1.
LIC. NO $O /DIG
u No.
Address S / Mc)(n2/2Al2 Sr Wit, t//wit
Alt. Tel. No. o f4---ay
coverage
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance or its sub-
stantial equivalent as qui d by Massachusetts^ General Laws, and that my signature on this permit
applIif
thi eq ement. Owner I 1 Agent Ill (Please check one)
Owner or Agent)
Telephone No. sm — 736 --a99O7 PERMIT FEE S
Effective: July 10, 2000
§ 10-176 ELECTRICAL PERMIT FEES
•
NEW HO I S:
(1) Comp •to residential wiring,includes sevice, outlets,major appliances:
a. With oil or gas burners and garage $ 80.00
b. With electric heat $ 95.00
(2) emporary service and work meter $ 45.00
3). Garage, separate from home $ 40.00
(4) Major appliances, 2 or more $30.00
(5) . Outlets, recep.,_swiL, fixt., old house,.perunit $50.00
(6) Increase or replace service $ 50.00
(7) Swimming pools $40.00
(8) Fire alarms, burglar alarms $ 30.00
(9). Oil burner or gas burner or electric heat • $ 30.00
(10) Annual permit $250.00
(11) Carnivals-concessions $ 50.00•
(12) Commercial:
a Estimated cost $1,000.00 to $3.000.00 $ 40-00
b. Estimated cost, each additional $1,000.00 $ 4.00
(13) Reinspection, each $ 25.00
(14) Surcharge for commencing work without a permit DOUBLE
(15) Late application surcharge fee, per day $ 50.00