EP-185-96 1 he U-ornmonweatth of Massachusetts /J' � 4
' '' ' Department of Public Safety _ r..." ,.,
rpm
•'i1�:'i BOARD OFoi: r+�> a r.. Checked �.�(.�
•,,.. FIRE PREVENTION REGUL11710NS 527 CMR IZOO 3/90
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
AU..wok a Ass perivnncd in aces•denee with Ilse Masaachasatu Electrkal C .S. 7 CMR 12:00
(PLEASE PRINT IN INK Oil ALLINFogHAIi'ON) Date
City or Town of - 3.I:dlc 1\ To the Inspector of Wires:
The undersigned applies for a permit to rfora the electr cal work described{� � below. c°./
Location (Street &Number) \ '�t1,`e-. — —rrpCt�� \�5,� .`�1� 140.` /4° 7
Owner or Tenant' �j�Z� e ' 1 t c_tn PN e) ,
Owner's Address •
Is this permit in Conjunctionwith a building petait: Yes [Er-No (neck Appropriate Box)
Purpose,of Building Utility Authorisation M.
Existing Service Amps / Volts Overhead 0 Uad
Ltd❑ No. of Meters
Nei, Service Asps / Volts Overhead'❑ Uadi 0 No. of Meters -
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work VNe, a.c_.VI mL i
No. of Lighting Outlets No: of Bat Tubs No. of Transformers Total
No. of Lighting Fixtures Sviauiag Pool Above In- xVA .
d. ❑ .
S� >Srnd. ❑ Generat
ors I<VA
No. of Receptacle Outlets No. of Oil Earners No. of Emergency Lighting i
Battery Units
No. of Switch outlets No. of Gas Burners FIRE ALARMS No. of Zones
•
No. of Ranges Total
.; So. Detection and
No, of Air Cond.
Initiating Devices
f Beat Total No. of Disposals No. o s T XII No. of Sounding Devices
No. of Dishwashers Space/Area Beating KR ;No. of SelfSorComaintained
De tection ng Devices
No. of DiyC.s Heating Devices KW Local❑tbniciConnectio 1n❑Other
No. of Water Heaters l37 No• of No. of Low Voltage
Signs Ballasts Wiring -
No. Hydro Massage ILbs No. of Motors Total HP
OTHER: e- r
1 oil Lam,
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts Central Lava
I have a current Liabili Insurance Policy including Caepleted Operations
Coverage
0
f equivalent. TS(D.l100 I have sutaitted valid proof of same to this office. viz( NO substantial
you have checked TES, please indicate the type of coverage.by checking the appropriate box
INSURANCE EOND ❑ OTHER❑ (Please Specify)
Estimated Value of Electrical (Jock S
S` ` (gicpiriticr. Date)
Work to Start Inspection Date Requested: Roult Final
s-Signed under the penalties of perjury;
j (AA)
NAME A R ty1A 1 4 -.. - C Ov'2,.c�A.; rs,J e. /'. �� LTC. Na. / ! �S fl -
Licensee RR m 0 .1 Cots Q._ I,/1 v eSi;na .. /.Tj fie% (. .�ti' . HO. q fa A
Address is--0 lik, M-rt=2A, Aue. MANS-c1( 011A, 0 Ot-tPus. Ie1. N). 5 U- - � �-7Li
(AMER'S 1}1SI7RANGE WAIVER: 1 en aware that the Licensee Alt. /el. No. G
does not have the insurance coverage or its suo-
scantial equivalent as required by Massachusetts General wcI , that ay signature on this permit
application Waives this requirement. Owner Agent (Please check one)
•
• Telephone No_ PERMIT lk± S
(Sigrucure of Owner or Agent)
•
•
^ i\J-.. •-•.k
04,_____--, "-T.-3_
x .5
Z.
iP., ' •)-, -- , "
i a) 1)
J ..E: "
.,Z
1,
s z oIr. no
' z° ,,.,
r
al
Z O rs. �I U• �z can
z ag it I - ; " j.-g 1a ` Z
z 4 E>m 1 19 O. �J CEj c i �� It
_.
=� O4 O -1 — -� 12
q _
vZ < ..� Im
H Z / Q. Q t o
�'�s %� O U cJ-
Q
•
x.
� .�, /i,
:�' A panIaaa {
// t'' __ --S- 6 ez, pied 4unoWd
adA1
/ "- ►y' J, - - t. -v /J / / UOIwJO1
2/1"( Jaum0
F ----75WOyy paniaDaJ
r
:.
,.
, , i - ,...." alea
_.. � ON _ ?
to
.ON 11W213d w`� �9a
E. 7.'` j//a AIf1OW121va 1O NMOI- 4`•Rino'y
F 11W213d 1103 1d13D3 J