EP-65327 TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 5 7
-1820 . F : 508-910-1838
TAX ISSttJES9O
Name: ' !f ,''.., ,: Property Owner: , t , t •,r# Date,c !e` `tli
. : r Job Location: 'r) ; , , i .4 it rx ,/ Map. Lot: -'
Description General Ledger#'s Ref. # Amount
Bu' -&;Building Misc. 01000-44105
Ell 01000-44106 r;
Plumbing & Gas 01000TWOF DARTMOUTHTrench Safety 01000GOL@ECTOR'S OFFICE
Other Department Revenue 01000-42420. „
„rL. 2 8 10
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By 144' t � .R•�^'-
THIS IS NOT A PERMITILICENSEFOR BUILDING, ELECTRICAL, PLUMBING OR GAS
C.ommonwealt/ a/Madiaciaietti Official Use Only
_* 6532 7_ l Permit No.
..Department o/. ire 3eruice� ���
__�_�_ Occupancy and Fee Checked� -- —
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 C 12.00 ::'
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: is/c 9 /?v l l
City or Town of: I t 1c . .) 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) 35 { k.t T_ L-PcN.b RID. r
Owner or Tenant GRR UD-t- L'/-TZ F}3-LIR 1. - )Z a- Teleph o. -9 (-62 r
Owner's Address .12:0 ).._UC.`' )_�-..raz- 20, , Di free 1- i inA-SG y
Is this permit in conjunction with a building permit? Yes [1 No k- (Check Approte Box)
Purpose of Building 2E31D E LICE Utility Authorization No.
Existing Service Amps PO /oN°Volts Overhead Er Undgrd n No.of Meters ,1
New Service Amps / Volts Overhead n Undgrd n No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: nSP Cir0 N Q (L(STPR RECOMIJ
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires /y No.of Ceil:Susp.(Paddle)Fans ( No.of Total
Transformers KVA
No.of Luminaire Outlets C . No.of Hot Tubs Generators KVA
No.of Luminaires / Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting
grnd. grnd. Battery Units
No.of Receptacle Outlets 3s No.of Oil Burners i FIRE ALARMS No.of Zones
No.of Switches f No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges A.. No.of Air Cond. Total No.of AlertingDevices
Tons
Heat Pump Number Tons KW No.of Self-Contained
No.of Waste Disposers
Totals: Detection/Alerting Devices
No.of Dishwashers Z Space/Area Heating KW Local❑ CIunieonnectioction ❑ Other
C
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water
t KW No.of No.of Data Wirin
._ Heaters 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.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: /a- -.b(/ 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 coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: LIC.NO.:
Licensee: G€RA-L iD souZ.4 Signature GLe.„,c-„ e Jc..-c LIC.NO.: 31Ccr)3
(If applicable,enter "exempt"in the license number line.) Bus.Tel.No.:
Address: .1D0 IUGy L.27T[ RD, Dne- •d`1'1C1)1L (Y1>rl��,
Alt.Tel.No.: -020-(-5-7Q I
*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insuLaRce 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 ee
Signature J U Telephone No. 9.Q �I -69 PERMIT FEE: $ .
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