23B-029 16 Dana elec permit 2017-05-15Official Use Only Commonwea!tli o/ 'YfJa,!iJaclU6eru
J)epa,,tmerd o/ J-ii•e Sell'v]cad ti?=t2-1 9{.;2
F FIRE PREVENTlON REGULATIONS (leave blank)
Eloctn~,o~t't~ar ) . ~ FOR IP!ERM~T TO fPfER!FORM lEL!ECTRJCAl WOIRK·
be performed in accordance with the Massachusetts Electrical Code ~C), 527 GiMR 12.00 J'?-//2{5{.P/f$"ll)
(PLEASE PRINT IN INK OR TYPE ALL INFORMAT. ON) Date: . '5 \ \ 9.. \ \ ~ ''$/ d{' .4()
C:i.fy or TowID.of: c To the Inspector of Wires:
By this application the unddrsigned gives notice of his o her ~~ntion to perform the electrical work described below.
Location (Street & Number) f\ fO r\ 0 't":'_ --''-""'----=--'i---'-~--=-......_---------------=--
Owner or Tenant __ .=.t::::_,,,.'--'-~"'--'~"--l;~'--~-===-·-----------Telephone No.'~ ab a )tl l..O
No 0 (Check Appropriate Box)
Utility Authorization No.
Is this permit in conjunctio1! with a building permit?
Purpose of Building 5t::.t3. ~o()v.,..S.
Existing Sernce Q.oo Amps / Volts Overhead~ Undgrd D -N-o-. -of_M_e_t-er-s--D<..._-...,-_---
New Service ~ Amps Volts Overhead~ Undgrd0 No. of Meters --'-7-
Number of Feeders and Am pa city ~
L d N f p d El t . I w k tv 1...,) ft ~ -c ~ \·o-it> "(Loo s ocation an ature o ropose ec rica or : "el c.. ........ \ \"\ 11'\, 1-..J (_~, --I ------Complet'tbn of the-following table maybe _;aived,by -the Inspector qf Wires, ~-· .. : .. -_ ..... . -.... ~., ...... ··--·~. ··,.
No. of Recessed Luminaires J.~ No. of Ceil.-Susp. (Paddle) Fans No. of Total
Transformers KVA
. -No. ofLuminaire Outlets No. of Hot Tubs Generators KVA
No. of Luminaires S . . p 1 Above D In-D .No. ot Emergency L1gntmg WlIIlmmg oo e:rnd. grnd. Battery Un.its
No. of Receptacle Outlets, ~{) No. of Oil Burners FIRE ALARMS jNo. of Zones
.
1< --No. of De:tection and No. of Switches No. of Gas Burners Initiating Devices
No. of Ranges No. of Air Cond. -Total No. of Alerting Devices Tons
No. of Waste Disposers Heayuip I NumberrTons ....... j KW .......... No. of Self-Contained
'Ota s: . . · Detection/ Alertine: Devices
No. of Dishwashers Space/Area Heating KW D Municipal Local Connection D Other
No. ofDryers ,. .. Heating Appliances KW Security Systems:*
No. of Devices or Eauivalent
No. of Water KW No. of No. of Data Wiring: Heaters Sie:ns Ballasts No. of Devices or Equivalent
Nci. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring:
No .. of Devices or Eouivalent
OTHER:
'' . . _ JL r"i t' _ Attach addi~onal detail if_~esired, o_r as requzred by the Inspector of Wires.
Estimated Value..9/Eleqtrical Work1f-_ ·~o 'O O (When required by mumcrpal policy.)
Work to Start: bi 1:$ / /'J Inspections to be requested in accordance with 11:EC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no pennit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "comp-Jeted operation" coverage or its substantiaJ equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: msURANCE D BOND D OTHER D (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRMNAME: ~~..... S . .Sc~L _ UC.NO.: ___ _
Licensee:---------------Signature ___________ _ LIC. NO.: ------(If applicable, enter "e;,;empt" in the license numbe1· line.) Bus. Tel. No.:. _____ _
Address: Alt. Tel. No.: _____ _
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" Lii:;;ense: Lie. 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) J&1 owner D owner's agent.
£;::[~~gent ~ / · ,3~ -Telephone No. %0 7t/ 1,,0 I PERMJT FEE: $ l\:E!''® '-'
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