EP-43268 TOWN OFF'aDARTMOUTH 11 5
BUILDING RECEIPTS g
.�� COLLECTOR'S OFFICE - f:
Na ,,',�"� , ' ,, Property, r _ Date: ,f b j-
����t" �•; ,�, ji.��1,_ _�f,,,��t. Owner: j�'-- '� � �` • �.
Job Location: i'/C.`. •�/�'.;'J '"`" 1 /} .---, , ..__.
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�•'` f �} White Copy-Collectors Office
` " Mellow Copy-Customer's Receipt
Plot: ` Lot r- `
t ;' . ---# ?ink Copy-File Copy
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21 Green Copy-Building Department
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Phone: 0 - ISSUES
MAJ13
Description General Ledger#'s Ref.# - Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106 `` , - $
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420
This is not a Permit or License for Building.Plumbing or Gas Received By: • '- --
7 V2/Commonwealth of Massachusetts Official Use Only
i►—*= t't Permit No. ,
►= Department of Fire Services l �`'
IF Occupancy and Fee Check d _
-,-` e. BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05]
`.,...-, (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL ORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYP L ORMATION) Date: c fr 6
City or Town of: �,, /" Gv' To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described bel w.
Location(Street&Number) k 1 /477° 1�hZ9
Owner or Tenant
1d7/2 J r/2/;/1-i- Telephone No.
Owner's Address '�`''<, (J -�'"`j—
i Is this permit in conjunction with a building permit? Yes ❑ No 52� (Check Appropriate Box)
Purpose of Building Utility Authorization No.
ks 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:
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp. Trans(Paddle) Fans T
Trformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
* Above In- No.of Emergency Lighting
No.of Luminaires Swimming Pool grnd. ❑ grnd. 0 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
Total
No.of Ranges No.of Air Cond. Tons No.of Alertingevices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: Detection/Alerting Devices
Municipal i
No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other 1
No.of Dryers Heating Appliances KW ecurrty stems:
o. quivalent
No.of Water KW No. of No. of Data Wiring:
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: 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 ains and penalties of perjury,that the informal' n on this application is true and complete.
FIRM NAME: �iz-1 ok,5 .v-t awe St o,tykiA /,1 LIC.NO.: 1 0 0 5 C
Licensee: Ink& 1 can l er Signature() LIC.NO.: 3 00 5 D
(If applicable, enter "exempt"in the license number line.) Bus.Tel.No.:C-I0I)33.3 '940 y'
Address: c)q /4IA„'an Raaci Ai n col tZ . 02-86 -- Alt.Tel.No.:
*Security System Contractor License required for this work; if applicable, enter the license number here: SS CO O a I E'y
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) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $ v '`c'•-
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