EP-62356 ,_,.....,,
TOWN OF DARTMOUTH
r% titqlEGE IPTS
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Name: 1, , rroperty ,-,„, _. ,. Date:
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Job Locatlon: i „.,- . ,—___
/ ;, 1 • . 1:.„,---- White Copy-Colledlor's Office.
,,,, T:,,,= i'i J "1: , 1 iiii,y 7 Customer's Receipt
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Map: i Lot:
look ' n'Copy-Building Department
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Description General Ledger#'s Ref. # Amount
S T ' • ' '1
License & Permits - Building 01000-44105
License &Permits - Balding Apse. 01000-44105
License & Permits ltlectricayl 01000-44106
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License &Permit(- Plujnbie"
ng & Gas 01000-44107
License &Permits - Trench Safety 01000-44129
Other Department Revenue 01000-42420
THIS IS NOT A PERMIT OR LICENSE FOR BUILDING, PLUMBING OR GAS
Received By ,>-,./ 7-`(:' /,,,),_
Commonwealth o/f addaci udettd Of cial Use Only
=' t c�lW: Permit No.
t =�1= 2epartment°Piro Serviced
y�==tr Occupancy and Fee l - . d
� - 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(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR T ,E ALL FORMATION) Date: / 3/'//
City or Town of: 1 ) jt/HO T To the Inspector of Wires:
By this application the undersigned gives noti of his or her intention to perform the electrical work described below.
Location(Street&Number) 7 C (A,lE' 44i25 1eD
Owner or Tenant hrLi art,
A/ �� " Telephone No.
Owner's Address y Od 6-pit)/ /iz f,WOj20 AJC9, / ' _5 06 3
/
Is this permit in conjunction with a building permit? Yes n No ❑ (C eck Appropriate Box)
Purpose of Building 5'/y1) /b A. /pN& Utility Authorizat' n No. 7/
n D Existi Service l!� Amps / b Volts Overhead. Undgrd No.of Meters
g P ltD �� � g /
New Service Amps / Volts Overhead n Undgrd No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 4L042,c6 eGg(//Cr Agie,QN CL e643lL
Ai e n D 02 g_k0/4.1i2 b /d D5
Completion of the following table may be waived by the Inspect,r of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp. T r(Paddle)Fans Tr.of T I sformers KV••.
No.of Luminaire Outlets No.of Hot Tubs Ge erators KV'
Above In- No. it"Emergency Lighting.
No.of Luminaires Swimming Pool grad. ❑ grad. ❑ Batt•ry Units
No.of Receptacle Outlets No.of Oil Burners FI• ALARMS No.of ones
No.of 0 etection and
No.of Switches ' No.of Gas Burners Ini Sating Devices
No.of Ranges No.of Air Cond. TotaTons No.of A : ting Dev' es
Heat Pump Number Tons KW No.of Self- I ained
No.of Waste Disposers Totals: Detection/Alerting Devices
`' Municipal
No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems:*
K
No.of Devices or Equivalent
No.of Water , 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: .5O• DO (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 FA BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: 5 G/ph b,F d i. //c77i iC/ LIC.NO.:6,2 6 J 0
�cSG�o AS Sc. Si ature '
Licensee: y gn C ZQ,4,G,o LIC.NO.:
(If applicable,enter exenz t"in the license number line.) Bus.Tel.No.:5 (p�Z
Y ' 91 D 3
Address: /79 P®(f9, , c4 v' " /Jf rc i d /G / /0- 0.172 Alt.Tel.No.:
*Per M.G.L.c. 147,s.50/-61,scurity 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 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: $
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