55 Application to Perform Electrical Work 1996 The Commonwealth of Alossachusetls
Deportment of Public Safety
(30A11O DE FIRE PREVEN11011 REGULAI1ONS 527 CMN 12.00
x.30
9s�Gs3_.
3/90 r��r d, fie..e
APPLICATION FOR PERMIT TO PERFORM ELECIRICAL WORK
All.ark to be pubrmcd In accordance willed.. Macenchurnu Eleurital Code, 527 CMFI 13:00
(PLEASE PRINT III II1K CR TYPE ALL INPOREATION) Date / / -- 20 - �G
City or Town of F LOQ<an/
To the Inspector of Wires:
The undersigned applies for a permit to per(otn the electrical work described helots. -
Location (Street a Number) S .\ /V k /IV 5 1
timer orb TF\ .S FNTrue is FS !NC, c..
Umcr•s Address mil( t eQ ■VD (.l VU�hi LO a.�et.- V rLA (itQG (1
�o et (6 T
Is this permit in conjunction with a building permit:
Purpose of Building
Existing Service
Hew Service
Amps
(lumbar of Feeders and kpac Thy
Volts
Volts
Yes Rif. To 1R (Cheek Approprla to Box)
Utility Authorization NO.
wet 'cad 1_J unegrdlJ 11o. of Meters
wette:ad I_I hndgrdI I No, of Meters
Loca rion and Nature of Proposed Electrical Work
71 7,27+,.,0 SAG 0e/ tic r/is
/4l ci /2'6 ti 6 S /N s%N/N-C /'00/H5
No. of Lighting Outlets
tin, of lint 'Tubs
Into)
No. of Transformers KVA
No. of Li gut lag Fixtures 3
Above = grad. I I
Swimming Pool
Generators KVA
Ile, of Itecepts to Outlets (+
❑n, of Oil Burners
No. of Emergency Lighting
Battery Units
FIRE ALARMS Ilo. of Zones
Ilo. of Switch Outlets
No. of Gas Ilernets
No. of Ranges
F
iota I
No. of Air Cond. tons
rio. of Detection and
Initiating Devices
No. of Disposals
No. of (Putt ; Tot Total ToKWI
No, of Sounding Devices
No. of Dishwashers
Fpaac/Arc Pe_n'Ince KU
No. of Self Contained ec _
De n/awml: L..
_Lee of -
No. of Dryers
Heating, Devices KW
locnlD Ih,ntc(pmt Other
Connect lon
No. of Water Ileac rs KW
No, of Ho. of
Signs Ballasts
No. of Ho tots Total III'
Low Voltage
Wiring
No. hydro Massage Tubs
Ur11FR
2 G F I /1 eC_ l I?it tt-/ oo/K1 l F-1 Tr-h.eny
INSURANCE COVERAGE, Pursuant to the requirements of Massachusetts General Laws
I have Cu ent Liability Insurance Policy Including Completed Operations Coverage o its substantial
equivalent.current LI ILO LSd I submitted valid proof or same to this office. TESL] NO IQ
If you have checked YES, please indicate the type of coverage Eby checking the appropriate box.
INSURANCE U BOND L OILIER O (Please Specify)
—(Explra[ion Dater
Est United Value of Electrical Work S Ie
Work to Start /(- 2.2 -76 Inspection Date R V
Requested: Rough J( L L CiSLFgnal
Signed under the penalties of perjury:
FIRM HAIIE LIC. NO.
Licensee tit/5$ii CL 6 /4/V 7%R(/5 Sij'naturc 74,424 -km tsvl'tVSa_ LIC. NO. /C-7 % j__
Address r( 6(-//es rt,uj Sr fist 1144 0/O yo Bus. Tel. Nu.
Alt. Eel. No. 7 E o n,
OWNER'S INSURANCE WAIVER: I am re that the Licensee does :rot have the insurance coverage rage or Its sub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this [nit
appl ilcatl(Rn valves this requirement. (Neer Agent (Please check One)
• �— Tf�j F wttildV lephnn,• No. SU (Y-0-t l� PERMIT FEE S
(QRltnvture of Ow',di or Agent) __