EP-137-96 RECEIPT FOR PERMIT
ouTy TOWN OF DARTMOUTH /` l •—3
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Amount Paid C' 77
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RECEIPT FOR PERMIT
Om. . TOWN OF DARTMOUTH / '"*-3!(f;
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PERMIT NO.
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Date
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t = =__6 Permit No.
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APPLICATION FOR PERMIT TO PERFOF M,.EL-ECTRICAL WORK
Massachusetts All work to be performed in accordance with the MassachusettsEle saes Code-. 17 CMR 12:00
(PLEASE PRINT IN INK O TYPE ALL INFORMATION) 4 l' at 9'_
City or Town of i 2 Ire Z To the Inspector of Wires:
The undersigned applies for a permit��t{o perform the elect{ A;I,`moktkldescriD i i�i+� T' e C/
Location (Street & Number) / Medejr- -5 /znt - 191� �'(J f7 a& O
Owner or Tenant /'1�i! ✓ 19/�/rile, e it .j ' /f h
Owner's Address C 5 L( 0<a (�C 9 l j .
Is this permit in conjunction with a building permit: 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 �� , �Ir �-�
Location and Nature of Proposed Electrical Work /J, ..2 tsf�/VJ --TTL_1
2
cfilirt-Yil //3/,LL7 "7— t r1/G6'
No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total
RVA
No. of Lighting Fixtures SwimmingPool Above In-
grnd. ❑ grnd. ❑ Generators KVA
No. of Receptacle Outlets No. of Oil Burners Bao. oftteryEUnitsncy
Lighting
No. cf Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones
No. of Ran es f Total ). No. of Detection and
8 No. of Air Cond. / tons , Initiating Devices
No. of Disposals No. of Heat Total Total No. of SoundingDevices
Pumps Tons KWa
No: of Dishwashers Space/Area Heating KW No. of Sell Contained
Detection Sounding Devices
lb. of Dryers Heating Devices KW Local❑ Municipal ❑Other
No, of No. of Low Voltage
_ Connection
No. of Water Heaters KW
Signs Ballasts Wiring
No. Hydro Massage Tubs ' No. of Motors Total HP
OTHER:
INSURANCE COVERAGE:Pursuant to the requirements of Massachusetts General Laws
I have a current L bilit Insurance Policy including Completed Operations Coverage or.i substantial
equivalent. YE 51 NO 0 I have submitted valid proof of same to this office. YES NO ❑
If you have c -cked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE Ai BONb ❑ OTHER t�1p�❑ (Please Specify) / /AJe 6 `%4 7
(Expiration Date)
Estimated Valoe df Electrical Work $
Wuk,to Start Inspection Date Requested: Rough Final
Signed under the penalties of perjury: ••
FIkM NAME LIC. NO. r
Licensee Der.) Signature IC NO. 7Z....-
Address P6 52/teary r* 74r us. Tel. No. '
Alt. Tel. No. 57
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its subl .
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE S
(Signature of Owner or Agent)
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