Lederer_Jouzaitis-Northampton-EP App
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
City or Town of: __________________________________ Date: ___________________
To the Inspector of Wires: By this application, the undersigned gives notices of his or her intention to perform the electrical work described below.
Location (Street & Number): ____________________________________________ Unit No.: ________________________
Owner or Tenant: __________________________________________ Email: ____________________________________
Owner’s Address: ____________________________________________________ Phone No.: ______________________
Is this permit in conjunction with a building permit? (Check appropriate box) Yes No Permit No.:_________________
Purpose of Building: _____________________________________ Utility Authorization No.: ___________________
Existing Service: _____________ Amps _____/_____ Volts Overhead Underground No. of Meters: _____
New Service: _____________ Amps _____/_____ Volts Overhead Underground No. of Meters: _____
Description of Proposed Electrical Installation: _____________________________________________________________
______________________________________________________________________________________________________
Completion of the following table may be waived by the Inspector of Wires.
No. of Receptable Outlets: No. of Switches: Generator KW Rating: Type:
No. Luminaires: No. of Recessed Luminaires: No. Wind Generators: Wind KW Rating:
No. Appliances: KW: No. Water Heaters: KW: No. Transformers: Total KVA:
Space Heating KW: Heating Equipment KW: No. Motors: Total HP: Total KW:
No. Heat Pumps: Total KW: Total Tons: Fire Alarm System No. of Devices:
Swimming Pool: In-Grnd. Above-Grnd. Hot-Tub No. of Self-Contained Detection/Alerting Devices:
No. Oil Burners: No. Gas Burners: Video System No. of Devices:
No. Air Conditioners: Total Tons: Telecom System No. of Outlets:
No. Energy Storage Systems: KWH Storage Rating: Security System No. of Devices:
Solar PV KW DC Rating: Solar PV KW AC Rating:
No. of Modules: Roof-Mount Ground-Mount
No. of Electric Vehicle Supply Equipment:
Level 1 Level 2 Level 3 Rating:
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: _________________________________ (When required by municipal policy)
Date Work to Start: _________________ Inspections to be requested in accordance with MEC Rule 10, and upon completion.
FIRM NAME: ___________________________________________________ A-1 or C-1 LIC. No.: ____________
Master/Systems Licensee: __________________________________________ LIC. No.: __________________________
Journeyman Licensee: _____________________________________________ LIC. No.: __________________________
Security System Business requires a Division of Occupational Licensure “S” LIC. S-LIC. No.: __________________________
Address: ____________________________________________________________________________________________
Email: __________________________________________________________ Telephone No.: ________________________
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
Licensee: ____________________________Print Name: ________________________________Cell. No.: _______________
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee
provides proof of liability 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 issuing office.
CHECK ONE: INSURANCE BOND OTHER Specify: _____________________________________
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: _______________________________________________ Tel. No.: ________________________________
Signature: ____________________________________________________ Email.: _________________________________
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.: __________________________
Occupancy and Fee Checked: ____________
[Rev. 1/2023]