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Baatz-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]