EP-41027 TOWN OF DARTMOUTH 41027
BUILDING RE9EIPTS
; f COLLECTOR'S OFFICE 7
Name: i f �.'- p "_ Pro ert ,� ,�� Date: ,J��� ;/ /n -"/l
Job Location: j� i J �f / C .„71 - .{ Ate/7c____
' Whi e Copy-Collectors Office
Plot: J (if/la f Lot:
" ° Yell Copy-Customer's Receipt
!!! f �yy� -Pink opy-File Copy
Ai c
Phone:
1 2 6 � re Copy-Building Department
MAJ13
Description General Ledger#'s ter.it Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105
License&Permits (Electrical 01000-44106 i l/;< C1, of vJ
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420 j
I i `
This is not a Permit or License for Building,Plumbing or Gas Received By;,/ /
Commonweakt o/rrladdachudetld Official Use Only
Itccyy�� c�77 Permit No.
�t I 1J- epartment o1 Jire Serviced
: Ib BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
o, �il 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: Z6�� y�t~L"�
By this application the undersigned gives notice of his or her intention to perform the electrical work described 1 �
Location(Street&Number S /tee: Ze _LEA-s"e/ /"F/ 0
Owner or Tenant ra.-v Q/2 triGf/r,/ Telephone It
Owner's Address ._y9ne_
Is this permit in conjunction with a building permit? Yes Noll (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead I I Undgrd No.of Meters
New Service Amps ( Volts Overhead I I Undgrd I I No. of Meters
Number N Feeders and ro Ampacity /� . � ���
Location and Nature of Proposed Electrical Work: /c�c� � �_ r�
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.ofTransfo mars KVA
No.of Lighting Outlets No.of Hot Tubs
Generators KVA
'*No.of Lighting Fixtures Swimming Pool Above In- No.of Emergency Lighting
gmd. grad Battery Units .
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
Ttal
No.of Ranges No.of Air Cond. To
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 — Municipal
Connection Other
No.of Dryers Heating Appliances KW Security Systems:
No.of Devices or Equivalent .
No.of Water No.of No.of Data Wirin
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,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND I I OTHER I I (Specify:)
(Expiration Date)
Estimated Value pf ctrifdl..Work: (When required by municipal policy.)
Work to Start: of 26/d S Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is try and complete.
FIRM NAME: So,,- cl/.se - Z cc ' 5c-,i,} eC,re/Ca-t! J-e✓t"e clic.NO. .- V3 9- 2
Licensee: c• it Signature LIC.NO. 3 4 7?A
(Ifapplicab e,eft r"exempt"i the license nu ber line.) r-� Bus.Tel.No.:9'eC s-C
Address: {� GC -r,...-,,/ "-pc, ...v."- /.linT 'm / —Alt.Tel.No.: 9,-/3//j
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. PERMIT FEE:$
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