EP-68004 TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT ,I I
✓ PHONE: 508-910-1820 FAX: 508.91 O TAX ��S
Pb 7k f/J1/�A Dat S,Name: i : r. .r1 i.'�) Property Owner:
Job Location: - !i ,% Map: 7 u Lot: Ai j t)`
Description General Ledger#'s Ref.# Amount
Building & Building Misc. 01000-44105
Electrical 01000-44106 T-. ,e 7 s 75' `
Plumbing& Gas 01000-44107 4 ic,°1. rOUTy
Trench Safety 01000-44129 M
` 222®t2
Other Department Revenue O 1000-42420
White-Collector's Office Yellow Copy-Customer's Receipt Pick Copy-building Dep1it',�m+G Z(I b9/rj/�J
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THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
Commonwealth a/m14a6AachudeUtd Official Use Onlynl
t —� - t ccyy�� rr�� Permit No. c O Ca y
° c7- 2e artment o 5ire..ervicea
, ___ P ir7S
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev:I/07] (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: /o—'/-/a_
City or Town of: Doi hnov.w, To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to performf the electrical work described below.
Location(Street&Number) 9'a At,//er, Pr ralkn- c (1 LU <LI
Owner or Tenant �(v }s cr„ /7Cr' ephone No. 77 y--27 2/7S 7
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No n (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead Ti Undgrd❑ No.of Meters
New Service Amps / Volts Overhead n Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: t,.,i, ,Ark (...H.tez y r 7-;cm,ef• S<. ,rr„ti..,tire)/
Completion ofthe followin• table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans T of TVA:
Tr No Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators EVA
o cove In- • ❑ No.of Emergency Lighting
No.of Luminaires Swimming Pool
rnd. rnd. Battery Units —
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
of Detection and
No.of Switches No.of Gas Burners No. Initating Devices
Total •No.of Ranges No.of Air Cond. Tons 'No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW tNo.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW .Local Municipal 0 �,
L Connection —
No.of Dryers Heating Appliances I{W Sec No urio Syf Devices or Equivalent
•
No.of WHeaters KW ter No.of No.of Data Wiring:
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,
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 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 0 BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: ,z LIC.NO.: _
Licensee: J , 4-7Y'vs Signature n�,�T- LIC.NO.: $o/5 S t=
(If applicable,enter "exempt'in the license number line.) Bus.Tel.No.: S yr �C i2-Jen,
Address: /o y r<,i..,.. - /4('- _ fci///r„-_ AA-0�7 y? Alt.Tel.No.: —
*Per M.G.L.c. 147,s.57-61,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)❑owner ❑owner's agent.
Owner/Agent _�
Signature • Telephone No. I PERMIT FEE: $ 7 5
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