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EP-49351 TOWN OF DARTMOUTH BUILDING RECEIPTS .. -°'' 's COLLECTOR'S OFFICE Name. .''--_ Property Date: .,,,a. /, --- k`, 1...�"t' .;= Owner: ' t ' / /...—i: / Job Location: s� COL LECTOR.s nFFiCE White Copy Collector's Office Plot: Lot:. j r , Yellow Copy-Customer's Receipt Y ._� EN Z odl Pink Co File Copy pp�p //�� 13 Green Copy-Building Department Phone: e- MMM AJ Description General Ledger#'s Ref.# Amount License&Permits-Building 01000 44105 License&Permits-Building Misc. 01000-44105 License&Permits-Electrical / 01000-44106 ;7 ` y;' . , License&Permits P.,lurrtt5 ng&Gas 01000-44107 Other Department Revenue 01000-42420 / a This is not a Permit or License for Building,Plumbing or Gas Received By: --f 7,":- ' -'6= rW Commonwealth of Massachusetts Official Use OM ' t1:11, = 2 / Permit No. �J�Occupancy and Fee Checked •1) BOARD OF FIRE PREVENTION REGULATIONS Permit 9/057 (leave blank) APPLICATION FOR. PERMIT TO PERFORM ELECTRICAL WORK AP work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPFALL INFORMATIO ) Date: 6..--//O City or Town of: 1,/Af"Z'T ,"f��/� 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) T-i+v �i ,J.,�� RP,� Owner or Tenant cJ QUA) Zj-: A,2e,65 'S Telephone No G5-F7.5 Y7 Owner's Address Is this permit in conjunction with a building permit? Yes I I No (Check Appropriate Box) .' Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead I I Undgrd i I No.of Meters i New Service Amps / Volts Overhead Undgrd No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: CO/i2/A © r �f c Ff t ,_t) CZ *Well *u` P d 1.6. >G c 0 b crpfz, s{ ).6 6t1 r/ 72> .510 r Ib,� ,v 0,t,t Completion of the following table may be waived by the Inspector of Wires. l No. of Recesse Luminaires No.of Ceil.-Susp.(Paddle)Fans No.ns KVTotA Transformers IMF A No. of Luminaire Outlets No.Of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above in- No. of Emergency Lighting gruel, 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 Total No.of Alerting Devices No. of Waste Disposers Heat Pump Number ITons I KW No.of Self-Contained Totals: t , Detection/Alertin Devices No. of Dishwashers Space/Area HeatingKW Local Municipalp Connection Other No. of Dryers Heating Appliances KW S ty Sms ecurivste :*� No.of Devices or Eauivaiert No.of Water r.�, No.of No.of le (Data Wiring: Heaters a`, Signs Ballasts No.of Devices of E;e➢usvaietit INo. Hyelromassage Bathtubs No< of Motors Total HPl'elecommunieations Wiring: No.of Devices or Lctuivaient — OTHER: Attach additional detail If—desired, or as required by the Inspector o/Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: inspections to be requested in accordance with MEC Role 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 cove, ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER Li (Specify:) I certifjr,Under the pains an penalties of pedury, that th,e information tion on this application is true and complete. FIRM NAME: tea, ikkr 0 110 .( I? LIC. NO.:f/ 0 3 r Licensee: Z7M O/jJ /269 Signature <✓ af applicable,,� e�tV� �st T empt" n the i'cen.' masher lx....) tins. €el. Nu.: ! •Address: Tj, t•'(x).9 . - llt."fi'el. No.: *Security System Contractor License required for this work; if applicable, iter the license number here: OWNER'S INSURANCE WAIVER: 1 ❑m aware that the Licensee does not have the liability insurance coverage not required by law. By my signature below,I hereby waive this requirement. I am tine(cheek one)J owner ❑ owner's agent. Owner/Agent f i Signature Telephone No. z PERMIT FEE: $ / CCC� r�