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I i e UTH - BUILDING DEPARTMENT RECEIPT 1 4 t 0
4 4 f i 301 1 1 8-WI 0-1 8 2 0" FAX: 508-910-1838
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Name: / ""L'i ' ci, ' /1-?:l',4/lir Owner: ' "-- , Dateii'l
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Job Location: i 4// / ' - g"1--‘-'" 4 '/''(.1--"" 1/..2\--1 Map: 7' (/ Lot:
Description . General Ledger#'s Ref.# Amount
Building&Building Misc. 01000-44105
Electrical 01000-44106 I ; 7eji....4,1---4_, 7/7[72:i))
Plumbing & Gas 01000-44107 .:7, ' I'
Se7.4) 4t)ef
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Trench Safety 01000-44129 m • i-Lv /1/
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Other Department Revenue 01000-42420 '\
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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 o/Ma6daclutJett4 Offici4l U e7y, f
J42D'_`== 't c� Permit No.
6-41=—a 2)epartinent o/giro Serviced
= 4
._t_1=j Occupancy and Fee Check d ,
BOARD OF FIRE PREVENTION REGULATIONS [Rev. '^
' s1/07] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICA WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.10
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 9 q
City or Town of: nI}R i I p J T 14 To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described -low.
Location(Street&Number) 18 ?l/l6 r s t.„4 Al D 1-- A
Owner or Tenant ST e v c i 4 EV A N G.L L ii 0 Telephone No.
Owner's Address I $ PINE ISLAND R a. CA R i Vitt LIT-4-4 .M4
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building R t_5:D t<iu'7 M L. Utility Authorization No.
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: R O a So P PAN M 0 LA)t I: l41 Etal
1.i'ret4r--a
Completion of the following_ta.1. ' ' ed by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No. 1'' d Total
Trans KVA
No.of Luminaire Outlets No.of Hot Tubs Generators e� //1 , A
No.of Luminaires SwimmingPool Above In- No.of Fmergency(U t4 �i g
grnd. ❑ 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. Total No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump I Number I Tons I KW No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW cal❑ Municipal
Lo Li Other
Connection
No.of Dryers Heating Appliances KW Security Systems:* 1
No.of Devices or Equivalent
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 W�ring
No.of Devices or Equivalent
OTHER:
.) Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: i (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 pains and penalties of perjury,that the information on this application is true and complete
FIRM NAME: ,A►Ge.O l L. 0 i R t C. LA c a .ma1 n LIC.NO.: /6,,,ff 9.j
Licensee: S j p N E ri [.?,p R 0 i, t`Z Signature . . \K CaLs LIC.NO.:e 2 rj q 3
(If applicable,enter "exempt"in the license number line.) B s.Tel.No.:& .99ci.3 f
Address: Li'7 ?U GI C.-1 to ART C QTW /'ii A. b P 7 4 Alt.Tel.No.: t;G'R 4 9.tea 7f
*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 PERMIT FEE: $
Signature Telephone No.
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