EP-26570 TOWN OF DARTMOUTH2657 }
BUILDING RECEIPTS
COLLECTOR'S OFFICE
Name: — i r„ Property y �ltTlate: r,,
l'r 1 �y a=Y^f/' e Ownerry ft.v� Tow! DARTT09'S 0TRU
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Job Location: OCT 3
te Copy-Collector's Office
Plot: - Lot: '+ �/ Yellow Copy-Customer's Receipt
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1 u n i it, Pink Copy-File Copy
J keen Copy-Building Department
Phone: � 101 f r
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Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105
License&Permits-Bui1Misc. 01000-44105
License&Permits'Electrical J 01000-44106 r>J fie > l
License&Permits-PIumbing&Gas 01000-44107
Other Department Revenue 01000-42420
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This is not a Permit or License for Building,Plumbing or Gas Received By: 2/ %/ta°-I
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nc)E (DS3U--3- 7 7/,,7
Commonwealth of Massachusetts Official Use Onlc
fi11t � Department of Fire Services Permit No. c)-(p.7f
fiE) BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked fit)
':."-,! Sc [Rcv. t 1/99] (leave blank)
1 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be pert'onned in accordance with the Massachusetts Electrical Code(MECI 527 C 12.00
(PLEASE PRINT IN INK OR TYPE ALL��INFORMATION)� 1 Date: 24 QZ.
City or Town of: OAe m 6 To the Inspector of Wires:
/�/� By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
/ , ` Location (Street& Number)) 2 Ohv-4t DEC 9-1)1 Owner or Tenant MH46 E. ZJ"ENCJNS Telephone No.
Owner's Address 1 1
Is this permit in conjunction wit:: .:!:::::.:i::,; i:;:a:L'P Yes ❑ No ® (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters _
New Service Amps / Volts Overhead❑ Undgrd ❑ •' No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: up 4240,1 € saute., 5'5Te01`-I
Completion of the fol/owingtable may be waiver)by the Inspector of:f'ires.
INo. of Recessed Fixtures No.of Ccil:Susp.(Paddle)Fans No. of Total
Transformers KVA
No. of Lighting Outlets No. of Hot Tubs Generators KVA
No. of Lighting Fixtures Swimming Pool Above ❑ In- ❑ No. of Emergency Lighting
grnd. grnd. 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
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 �g
Totals: — Detection/Alerting Devices C�
No. of Dishwashers Space/Area Heating KW Local•
❑ Con is ton ❑ Other
No. of Dryers Heating Appliances KW Security Systems:
No. of Devices or Equivalent
No.of Water No.of No.of
Heaters KW Si Signs Ballasts Data Wiring:
g No.of Devices or Equivalent
No. Hydromassagc Bathtubs No.of Motors Total HP Telecammunicatiansw:iring: -.
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of If Tres.
INSURANCE COVERAGE: Unless waived by the owner,no pcnuit 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 ❑ OTHER 0 (Specify:)
Oes (Expiration Date)
Estimated Value of Electrical Work: 7� �,. (When required by municipal policy.)
Work to Start: 16 ' l6„9,Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I certii•, under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: ADT Security Services,Inc. ___..LIC.NO.: 1533C
Licensee: John S. Bassett Signature u �� LIC.NO.: 1533C
(If applicable. enter"exempt"in the license number line.) Bus.TeL No.: 78 1-27R-I t��
Address: 111 Morse Street.Norwood,MA 02062 Alt Tel.No.: 781-278-14 0 0 ..,.
- - OWNER'S INSURANCE WAIVER: I am aware that th L ensec-does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. 1 am the(check one)0 owner 0 owner's agent.
Owner/Agent
Signature .Telephone No. . I PERMIT FEE: $ uj�