EP-73454 i
TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 7 L 3 4
‘.._/ PHONE: 508-910-1820 F 9
Name: TAX issuislic,
i -L. Property Owner: I -.,r i...e._.v,,i ate:5 t/ I
/Job Location: / ✓`/ � :a < < 4.( ' `_ _ Map: `� Lot: 7
Description General Ledger#'s Ref.# Amount
Building & Building Misc. 01000-44105
Electrical 01000-44106 `"I i
hitcji A,
Plumbrii& Gas 01000-44107 8
Trench Safety 01000-44129
Other Department Revenue 01000-42420 SfW �y 4
11
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department By E G iG'tJ
THIS IS.NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
r DD //
Commonweadt4 o f adeachudettj Official Use Only
_, yS�'=_ i=�t c� c7 _ Permit;No.
at lepartment o/.}ire Serviced ��
Occupancy and Fee Checked ?�
�l` BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/'7] (leave blank)
APPLICATION FOR PERMIT 0 PERFORM E ECTRICAL WORK
All work to be performed in accordance with th Massachusetts Electrical Cod (MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFO TIO, Date: ---y'V
City or Town of: To the In pector of Wires
By this application the undersign d gives notice o his or her int 'on to erform e lectrical work dgst 0ed elo9
Location(Street&Number) / Rrx,,P . !,l �
Owner or Tenant / Telephoner No. ' , ...- /?�'
Owner's Address • /l
AP-
Is this permit in conjunction with a building permit? Yes n No r (Check Appropriate Box)
Purpose of Building Utility uthorization No: �'
Existing Service Amps / Volts Overhead n Undgrd Ft,'-' No.of Meters
New Service Amps / Volts Overhead Li Undgrd+LI No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: (, J ! , "-/
Id.. - A i i!J 0 �- ' �
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Completion of the foliown table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
-01 Transformers KVA
No.of Luminaire Outlets :,� No.of Hot Tubs Generators KVA
y Above In- No.of Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ g y g g
g grad. Battery Units
No.of Receptacle Outlets 3 No.of Oil Burners FIRE ALARMS No.of Zones
011
No.of Switches 3No.of Gas Burners No.of Detection and
Initiating Devices
Tot
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❑ Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW
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.
;Ns Estimated Value of Electrical Work: /en) (When required by municipal policy.)
Work to Start: 5"~ 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 issuin office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) l 5,,c) S,I certify,under the pains and penalties of perjury,that the information on this application is tr e and complete.
FIRM NAME: LIC.NO.:
Licensee: Signature LIC.NO.: lfJ
(If applicable, enter "exempt"in th ice umber e..) Bus.Tel.No.: L g
Address: j� Ug / �v / Alt.Tel.No.:7 71`/-. .r '-c`Y'S
*Per M.G.L.c. 147,s.57-61,security work requires Department oil ubli�ty"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:$ 7
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