HomeMy Public PortalAboutElectrical Permit ApplicationCommonwealth of Massachusetts Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked
[Rev. 1/07] (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.
Location (Street & Number)
Owner or Tenant Telephone No.
Owner’s Address
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.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Transformers
Total KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators
KVA
No. of Luminaires
Swimming Pool Abovegrnd.
In- grnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and Initiating Devices
No. of Ranges
No. of Air Cond.
Total Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump Totals:Number Tons KW No. of Self-Contained Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating
KW
Local Municipal Connection
Other
No. of Dryers
Heating Appliances
KW
Security Systems:* No. of Devices or Equivalent
No. of Water Heaters
KW
No. of
Signs
No. of Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors
Total HP
Telecommunications Wiring: No. of Devices or Equivalent
OTHER:
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.
FIRM NAME: LIC. NO.:
Licensee: Signature LIC. NO.:
Bus. Tel. No.: (If applicable, enter “exempt” in the license number line.)
Address: Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety “S” License: Lic. 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) owner owner’s agent.
Owner/Agent Signature Telephone No.
PERMIT FEE: $