EP-82594 ^iii TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 8 2 5 9 4
PHONE: 508-910.1820 FAX: 508-910-1838
''r
4 / A t......, ro6 ;,„
Name: } Property Owner: Date:
! d
Job Location: ..�((/,C)"0.1 6.A 0,.. 7
_ Map: Lot: 6 .,.
Description General Ledger#'s R # 1 Amount
ileling... uilding Misc. 01000-44105
Electric 01000-44106j.c rd
Plumbing& Gas 01000-44107 of a AR 1 Mo&°,1/4„
Trench Safety 01000-44129 i ,.
Other Department Revenue 01000-42420 "
r
4ric
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Depa ent�,_ eC 1 �dy £'(�G't/ri'"f
C A , _ .,
THIS IS NOT A PERMITILICENSE FOR BUILDING, `1'RICAL, PLUMBING OR GAS
Cammon uealth o,//laMacLetta fficial Use Only
j==M= Permit No. 0L
=a 2epartment of 3ire Jervicea
:14= Occupancy and Fee Checked <
. � BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C), 27 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 9 I c ,
City or Town of: tccrkWY'x>`l� To the Inspec r of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 4S Mece"\. Vv
Owner or Tenant <0(p Telephone No.
Owner's Address - —,_S— Vvt-et eiND 1 VO
Is this permit in conjunction with a building permit? Yes o _ (Check Appropriate Box)
Purpose of Building ,ems ___ Utility Authorization No.
Existing Servic Amps /&e jZ)Volts Overhead I I Undgrd n No.of Meters
New Service Amps / Volts Overhead I I Undgrd I I No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires Na.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Na.of Luminaires 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 f KW No.of Self-Contained
Totals: f Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW ,Local Municipal
❑ Connection El Other
No.of Dryers Heating Appliances , Security Systems:*
No.of Water No.of Devices or Equivalent
No.of No.of
Heaters KW 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 desiredvr 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 cover a is in force,and has exhibited proof same to the per t issuing ffice.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) /7
I certify,under the pains and penalties rjury,that the information on I/ his application is true an complete.
FIRM NAME: \ LIC.NO.:
Licensee: Signature LIC.NO.:
/
(If applicable,enter "exempt"in a license number line)
Address: �� Bus.Tel.No.:
*Per M.G.L.c. 147,s.57-61,secar`ity work requires Department of Public Safety"S"License: LiAlt. e.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)0 owner 0 owner's agent.
Owner/Agent I
Signature Telephone No. I PERMIT FEE: $
. Map 7 Lot ' - `�
r
d
'n fy 54•OF.O
oAO x:
CD
tit Ici
o 5. V:4'N'1,1..01. ,S*-F,
I
cra
b 44.
n Ell0 o
CD
I
co
ti A
141
H o
b r ,C2. 1z Z*4
a* a* a G o
ICI
i i
z e d d
tll CD CD � ' P H
b
do ft
g
o
tkalk
t
co
5 5 5 0 H.
C 6 o�
CD Co 0
0
O O
CONI coo
GsCO °°
b
N
CD
N
0
w