EP-56159 TOWN OF DARTMOUTH
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BUILDING RECEIPTS
3 6' I 5
PHONE: 508-910-1820 FAX: 508-910-1838
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Name: . . Property - Date: _ /
Owner: ,' 4 ---- .----' ,•. / / - i
Job Location: , , White Copy-Collector's Office
Yellow Copy-Customer's Receipt
, Pink Copy-File Copy
Map: 11 , -..03vgn,iy-Building Department
, 4. • TOWN OF DA_R 1
. .
Phone: MAR 17 2009\.
COLLECTOR'S OFFICE
Description General Ledger#'s Ret #
VIM 1 3 Amount
License &Permit0—\uilding\-, ) 01000-44105
License & Permits -iililding Misc. 01000-44105
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License &Permits -Electrical 01000-44106 -, -- ..;,,,,.•
License & Permits - Plumbing & Gas 01000-44107 _ . •
License & Permits - Trench Safety 01000-44129 NO TA)( ISSUES •
Other Department Revenue 01000-42420
THIS IS NOT A PERMIT OR LICENSE FOR BUILDING, PLUMBING OR GAS
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Received By:„.....‹.,-,----,--4 -7:-/-),
-To? . `6-,31 - a )
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Commonwealth
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BOARD OF FIRE PREVENTION REGULATIONS O` I/07] and Fee Checker S ,
[Rev. 1 07] (leave blank)
APPLICAll work to be ATION performed PErRMIT TO PERFORM ELECTRICAL WORK
dance with the Massachusetts Electrical Code(MEC),52700
(PLE4SEPR111ThTT IN INK OR TYPE AL INF RMATI '�r CMR
City or Town of: ve/ �1 Date: / ��
By this�lication the undersigned gives notice f U✓� To the Inspector ofW his o her intention to perform the electr ]t Tres:
Location:(Street&Number)
dirk described below.
Owner("Tenant Al LC
OWner'sAddress T¢'a LEE Telephone No.
Is this permit in conjunction with a building permit? e 7
Yes No ❑ (Check Appropriate Box)
Purposesf Building
• Existing;lervice Utility Authorization No.
Amps / Volts Overhead
New S�tace Amps ❑ Undgrd❑ No.of Meters _/ Volts
Undgrd Overhead❑ Und g ❑ No.of Meters
NumberiFeeders and Ampacity
Location�d Nature of Proposed Electric
al Work:
rk:
4L� C �`n
completion o the ollowin:table maybe waived by the Inspector of Wires
No.of Rcessed Luminaires --No.of Ceil.-Susp.(Paddle)Fans No.of
No.of hminaire Outlets Transformers Total
No.of Hot Tubs KVA
No.of Isrrinaires Generators K A
Swimming Pool Above .❑ In-
grnd. rnd. ❑ °'° mergency rg nagNo.of lleptacle Outlets Batt( Units
No.of Oil Burners
No.of Snitches
No.of Gas Burners FIRE ALARMS No.of Zones
No.of •etection and
No.of Images Initiatin: Devices No.of Air Cond. Total
No.of Waste Disposers Heat 'um Tons No.of Alerting Devices
Totalp i'umber Tons No.of Self-Contained
s: ...-.._..-..................
No.of Dishwashers • Detection/Alertin_ Devices
Space/Area Hefting KW t Local❑ Municipal
No.of h ens Heating Appliances Connection ❑ Other
No.of er KW Security Systems:* B -- ------
Seaters KW No.of No.of No.of Devices or E uivalent
Si: s Ballasts Data Wiring:
No.Hydrtmassage Bathtubs No.of Devices or E
No.of Motors Total HP Telecommunications Wia ringenr
OTHER No,of Devices or E a uivalent
ork: wu'0. .� Attach additional detail ifdesirecd or as required by the Inspector of Wires.
Estimatedalue of Eleetrica
to Sint: (When required by municipal policy.)
I Work S Inspections to be requested in accordance with MEC Rule 10,and upon coin
RASCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may
the licenser:provides proof of liabilitycompletion.
undersigns€certifies that such coverage is in force,and has exhibited proof of same to thepermit is
insurance including"completed operation"coverage or its substantial equivalent. The
CHECK ONE: INSURANCE i BOND ❑ OTHER suing office.
I certify,raider the sins and penalties o perjury, ❑ (Specify:)
FIRM NAME: c fP J ry,that the information on this
Dee_ `(i* S erU application is true and complete.
Licensee: 0( Y\ ; n L uzz
LIC.NO.: +� C
(If applicable enter "exemnr"in the ice Signature
Address: umber line T LIC.NO.:�5 C`-
lx-I`l �E(L f�,f d \t ', we,,►( o,�® �,, o®This.Tel.No.: 1%1- 3r)=-509
*Per M.G.I.c. 147,S.S7-61,security workrequires Department OWNER'SINSURANCE WAIVER: I am blaze that icensee does not have the ',I abil' Alt Tel No.: �� 3J��-���-��
Safety e License: Lin. coverage 1X��o ca3 required bylaw. By my signature below, I hereby waive this requirement. I am the(check one)insurance normally
Owner/Agent []owner
Signature0 owner's.a ent. ��/
Telephone No. PERMIT FRP% e
r,
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