EP-65092 e TOWN OF DARTMOUTH,- B !"DING DEPARTMENT RECEIPT 6 5 0
WI PHONE: 508-910-420 FAX: 508-910-1838
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Name: .ae2/ I ". Property Owner: Vi,
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Job Location: / , . f%' j L . -. / /" Map: Lot: /
Description General Ledger#'s Ref. # ,,,, Amount
Building &Building Misc. 01000-44105 �/
Electrical 01000-44106 f'eil r r
Plumbing & Gas 01000-44107
Trench Safety 01000-44129 b
Other Department Revenue 01000-42420
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL;PLUMBING OR GAS
_ Commonwealth.a/glladoach.tietto Official Use Only
c� c7 Permit No.
.-Llepartment of.}ire�ervicei
� 10— Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS p y
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[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 INFORMATION) Date: (l —3e !/
City or Town of: w h( MO 4'1-t1 To the Inspector of Wires:
By this application the undersigned gives of his or her intention to perform t e e ectrical work described below.
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Location(Street&Number) , Lai) AINC i----
Owner or Tenant s fe a e.... ..,bGz U i 5 Telephone No.
Owner's Address SGt.Wl e...-
Is this permit in conjunction with a building permit? Yes r No (Check Appropriate Box)
Purpose of Building —et,ir'� 1 e— Utility Authorization No. 3 A B Lf 1f 6 g
Existing Service Amps / Volts Overhead f I Undgrd n No.of Meters
New Service (b O Amps /ZO I i`tU Volts Overhead 1 I Undgrd [9 No.of Meters /_
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: `e,p 4 n-t{p U ,G o service__ '4--
t re- 51411 yc`rc& 1 e----,
Completion ofthefollowing table maybe waived bythe Inspector
p p for of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans T of
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
• I No.of Luminaires Pool Above ❑ In- ❑ No.of Emergency Lighting
Swimming grnd. grnd. Battery Units
i
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
M No.of Detection and
No.of Switches No.of Gas Burners Initiating Devices
No.of Ranges No.of Air Cond. Tons[ No.of Alerting Devices
Heat Pump Number Tons KW No.of Self-Contained
No.of Waste Disposers
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Water No.of No.of No.of Devices or Equivalent
Heaters SiKW ns Ballasts Data Wiring:
g 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: A,bot7 •-- (When required by municipal policy.)
Work to Start: it"'3e)—ul 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
ill ndersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
II certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: 7>01.1_9 a tril .1/i..`. £le.c=`'fCt e_ LIC.NO.: lb r3 2:6--
Licensee: �(xl c--orerI ��
J Signature TIC.
NO.:
(If applicable,enter "exempt"in the li er nse numb line.) Bus.Tel.No.:
Address: S Oa-4lei{e_. ST'T, rif e-v S h 6 p 1.— Alt.Tel.No.:S015—te0D—1 7
'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 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. PERNIIT FEE: $
17 Plat / Lot VI — 33
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