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The Commonwealth of Massachusetts time our
• Department of Public Safety Newts se.
I BOARD OF FIRE PREVENTION REOUL4710NS 527 CMR t200 �<�rre..s a .a, MCWh)
APPLICATION FOR PERMIT'10 PERFORM ELECTRICAL WORK
All work to be per6naed M accordant<with the Maaaachusens !Metrical Code, $27 CMR 12:00
(PLEASE PRINT IN 'NZ OR TYPE AIL INFOR'IATION) Date (e'— -Y O C7
City or Io.m of 174eJ n4ovr,/ Te the Inspector of Wires:
The undersigned applies for a permit to psr£orm the electrical work described helm..+,
Location (Street 6 Humber) 2 Q 4,k R 1 nfr L- >4
o ner or Tenant in gag \rl el ay S
1N
Owner'a Address ea OA.r K „D4L-r- -De Daa2Tmovrh mAt oa 247
I; this permit in conjunction with a building permit_ yes No 0 (Cheek Appropriate iate Box)
PP
Purpose of Building ut¢-ei 4,e Utility Au;horiution NO.
Existing Service 3 CD An / Volts Overhead ❑ Undgrd❑ No. of Meters
Now Service Amps / Volts - Overhead ❑ Vtdgrd❑ No. of Meters
Number of Feeders and Ampaeity
Location and Nature of Proposed Electrical Work ��U�nucJ�L;i ' ,ice�L`
No. of Lighting Outlets a a No. of Hot Tubs /0 'No. of.Transformers TKVA1
No. of Lighting Fixtures a Svim.ing pool Above r In- 1
_ grnd. lJ grnd, U 'Generators IBA
No. of Receptacle Outlets? S I No. of Oil BUners Y 'Bat er Emergsney Ligbc pg
_ Eattory Unitts p
No, of Switch Cutlets / I:to. ct Gas turners n( 'FIRE ALARMS No. of Zones
No. of Ranges "Total No. of Detection sod
No. of Air Cond. Cons Initiating Devices
No. of Disposals ry No, of pates total total No, of Sounding Devices
No. of Dishwashers 1 Space/Ares Heating KW No. of Self Contained
Detection/Sounding Devices
Ne. of Dryers A' Heating Devices d RW total❑ nicipal
!' Connection❑OCher
No, of No. of Low Voltage /
No. of Water Beaters KW
Sims Ballasts Wiring
No. Rydro Massage Tubs 0 No. of Motors Total RP
-
I-. /00efel4 i> .54,41, Parwe[.-
I1154:4ANa COVERAGE: Pursuant to the requirements of Massachusetts General Laws
i have a current liebilit Insurance Palley including Completed Operations Coverage or its substantial
equivalent. USED NO I have submitted valid proof of same to this office. YES❑ NO 0
If you have Eli
YES, please indicate the type of coverage by checking the appropriate box.OTHER[Jj BOND 0 R ] (Please Specify) Aif},t /flvrs', t Lo��
Estimated Value of Electrical Work $ 9 co.0 O lExpi ati Dat�
cerk to Start ///7Oe?. Inspection Date Requested: Rough Final
Signed under the penalties of perjury:
FIRM NAME
•�.p,.0 LIG. NO.
Licensee
isient r� signature -a,r6 _ ITC. No.,3 9126-
Address G6 ) it,.: i. 44, 7:..eel'a1/4. ETO..k7C1 Bus. Tel. No. (44 Ca),"-Ski.a R
OWNER'S INSURANCE WAIVER; I an aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachus s General Laws, and that ny signature on this permit
application waives this requirement. Owner Agent 0 (Please check one)
. (Signature of Owner or Agent) Telephone No. _ PERMIT FEE S
TOWN OF DARTMOUTH - .-- t
po si' 4
BUILDMIGIITECEIPTS
COLLECTOR'S OFFICE
Name: N- „/ ( Property ; �'! Date: ; /
Owner:
Job Location: J< a , ) W� - -
..A _ :- -�`fL_ eLrn 1 ✓t-{/)-CA
White Copy-Collector's Office
- Yellow CopyCustomer's Receipt
Plot: �% Lot -� ( r i� ,:N ��� i �n.�:i-, - P
s }a' COL' Er'TOR. OFr!CE Pink Copy-File copy
— Green Copy-Building Department
Phone: 7- -� )
) / / __ EK t/ ` OCT 2 4 2002 r _72 77
Description General Ledger1#'s — Ref.# Amount
License&Permits-Building 01000-44105 '. _ _ J_ __..
License&Permits-Building Misc. 01000-44105
License&Perm is-Electrical % 01000-44106 >)0 0 0
License&Permits-PTiirmbiing&Gas 01000-44107
Other Department Revenue 01000-42420
This is not a Permit or License for Building!Plumbing or Gas Received By: - 4
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