IMG_20190913_0002C,* ,n**o$l,f Wl^**L*w Official Use Only
Permit No.
Occupancy and Fee Cliecked
.ev. 1/07] fleave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All rvork to be perfomred in accordance ivith the N{assachusetts Electrical Code (MEC), 527 CMR 12.00
EI"EASE PRINT IN INK OR TI"PE ,4LL TA:FORilIATIOINI nnr,,,1 /#{i3 .hG;#ffiA
By this application the undersigned gives notice of-$is or her intenqion to perform the electrical work described belorv
l,ocation (Street & Number) B r.rflS ?,'), Ronl*
(-r. a c7 12J)epartnenl of J*" Jeriliaet
BOARD OF FIRE PREVENTION REGULATIONS
l,ocation (Street & Number)
0ryner or Tenant
C)wner's Address
LY Tetephone xo.{%s} I 4 {- A ft-;
OO 4,y**,1r LakZ iv(A-,tl
Is this permit in conjunction with a building permit?Yes B N, [ (Check Appropriate Box)
Purposeorsuitoine S ol q,f fia.rnt L,tility Authorization No.
Existiug Service Il4 A-p, -.- ./ Yolts Overhead I Undgrd I I{o. of Meters
l,{ewsenice fSEIV amps ltl,ttt., ?fz{Notts overheadffi undgrd f No.ofMeters --{*
Nurnber of Feeders and Ampacity.-I F<e)cr d e-rn-
LocationandNatureofProposedBlectricaiWork .,'l,.OtG f^W - B*ltr.a, 5]&,,"*"
' Completion of the falla,,vitt.q rdbie may be $'aived by the Inspector af ll;ires
h*o. of Recessed l,urninaires No" of Ceil.-Susp. (Paddle) Fans T*fiir.,*"* I fl$il zf,oo
No. of Luminaire Outlets No. of Hot'f,uLts Generators KVA
No, of Luminaires . Ahove r-r In-Swlmmlng tsool srnd. U srnd. L_J
N(). oI [mergency Lrgnung
Battery Liuits
No. of Receptacle 0utiets No. of Oil Burners FIRE ALARMS lNo. of Zones
No. of St'itches No. of Gas Burners No. of Detection and
lnitiatins f)evices
No. ofRanges No. of Air Cond. l0tel
Tons No. of Alerting Devices
5*. of \Yaste Disposerc NG. ol Self-Uontained
DetectionlAlertins Devices
Na. of Dishwashers SpaceiArea Henting KW Locarf 3ffi:11ff, il ottrer
No. of Dr1'ers Heating Appliances KW Securitv Svstems:t
No. bf hevices or Equivalent
. of WaterHeaters Kw No. ol- No. ot
SiEns Ballasts Data Wiring:
iYo. of Devices or Equivalent
ltlo. Hy'drornassage Bathtubs Fio. of Motors Total HP I elecommunications r iring:
\o. of Devices or Equivalent
()'THER:lO visit-s @ el(u
additional detail ifdesired, or w h the Wires.
Estimated varueorErectricarwork:$ q{ oqo. P ,i#*:#{##'Xtr3,:;::!,?{,?)*u"**
{ cerrtf1', under the pains and penulties oJ'perjury,, lhat the infonnation on this applicotion is tnre and complete.
FTRMNANTE: tri\$t Etea-|r,;e iluosFr'r;?r'*., f.* LIC.t{o.:
Inspector of
Work to Stafi:Inspections to be requested in accordance with NtEC Ruie 10. and upon completion.
niiSlrRdNCE,.GE: Unless waived by the owaer, no permit for the performance of electrical wor"k may issue unless
the licensee provides proof of liability insurance including'"completed operation" cqverage or its substantial equivalont. The
undersigned c€rtifie$ f}rat such coverage is in force, and hat exhibited proof of same to ttre permit issuing office.
CImCK ONE: INSTTRANCE f] B0ND f] OTHER [f (Specify:)
Llcensee: W, Ilir,,r.^ itohon Signature
|.. t-too t/rtr^,lP{*..nto?^t 5 Alt. Tel. No.:*PerM.G.L. c.147,s.57-6l,securityworkrequiresDeparhnentofPublicSafety*S"License: Lic.No.
0\VNER'S INSTIRANCIE \l AMR: I am arvare tlrat the Licensee does nol have the liabllig, insurance coverage nonnally
Olvner/Agent
Signature Telephone No.
5:
.-.ffi-Lig€Li;r'rl:,-
-*'3 EE-"E izi:q,t*E- rryt\'#-4,\\\€-l.r.-\\449r'
No.'*elef8_
Tel. No.l-_--
required b-v.- lau,. By niy signature below. I lTereb.v waive this requiretnent. I am the
Heat Pump I i\lmber I t ons IKllTnfnkr I I i
10r):' or. visil.