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Department of Fire Services
BOARD
OF FIRE PREVENTION REGULATIONS |
Official Use Only Permit No. Occupancy and Fee Checked [Rev.
9/05] (leave blank) |
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed
in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT
IN INK OR TYPE ALL INFORMATION) Date:
City
or Town of: To
the Inspector of Wires:
By this application the undersigned gives notice of
his or her intention to perform the electrical work described below.
Is this permit in conjunction with a
building permit? Yes No
(Check
Appropriate Box)
Purpose of Building Utility
Authorization No.
Existing
Service Amps / Volts Overhead
Undgrd No.
of Meters
New
Service Amps / Volts Overhead
Undgrd No. of Meters
Number of
Feeders and Ampacity
Location and
Nature of Proposed Electrical Work:
Completion of
the following table may be waived by the Inspector of Wires.
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No. of Recessed Luminaires |
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No. of Ceil.-Susp. (Paddle) Fans |
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No. of Transformers |
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Total KVA |
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No. of Luminaire
Outlets |
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No. of Hot Tubs |
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Generators |
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KVA |
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No. of Luminaires |
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Swimming Pool |
Above grnd. |
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In- grnd. |
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No. of Emergency Lighting |
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No. of Receptacle Outlets |
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No. of Oil Burners |
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FIRE ALARMS |
No. of Zones |
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No. of Switches |
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No. of Gas Burners |
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No. of Detection and Initiating Devices |
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No. of Ranges |
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No. of Air Cond. |
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Total Tons |
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No. of Alerting Devices |
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No. of Waste Disposers |
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Heat Pump Totals: |
Number |
Tons |
KW |
No. of Self-Contained Detection/Alerting Devices |
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No. of Dishwashers |
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Space/Area Heating |
KW |
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Municipal Connection |
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Other |
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No. of Dryers |
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Heating Appliances |
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KW |
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Security Systems:* No.
of Devices or Equivalent |
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No. of Water Heaters |
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KW |
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No. of Signs |
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No. of Ballasts |
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Data Wiring: No.
of Devices or Equivalent |
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No. Hydromassage
Bathtubs |
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No. of Motors |
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Total HP |
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Telecommunications Wiring: No. of
Devices or Equivalent |
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Attach additional detail if
desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by
municipal policy.)
Work to Start: 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 issuing office.
CHECK ONE: INSURANCE
BOND OTHER (Specify:)
I certify, under the pains and penalties of perjury,
that the information on this application is true and complete.
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*Security System Contractor License required for this
work; if applicable, enter the license number here:
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.
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