All electrical, gas and plumbing applications, together with the fee amount, must be mailed or delivered to:

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1 Application for Permit to Perform Electrical Work Massachusetts Uniform Application for a Permit to do Gas Fitting Massachusetts Uniform Application for a Permit to Perform Plumbing Work Applications and fee check All electrical, gas and plumbing applications, together with the fee amount, must be mailed or delivered to: Wilma Davis, Town Secretary Inspection Services Town of Hatfield 59 Main Street Hatfield, MA Scheduling of Inspections For an electrical inspection please call the secretaries office at to arrange for an inspection. Information needed includes the property address, name of the contractor, contact telephone number, and whether the inspection is for a rough or final. For plumbing or gas Inspections you may call Mr. Walter Geryk, gas/plumbing Inspector, at

2 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Permit No. Official Use Only 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 (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 Above grnd. Ingrnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices Total No. of Ranges No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self-Contained No. of Waste Disposers Totals: Detection/Alerting Devices Municipal No. of Dishwashers Space/Area Heating KW Local Connection Other No. of Dryers Heating Appliances Security Systems:* KW No. of Devices or Equivalent No. of Water No. of No. of Heaters KW Data Wiring: Signs Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP 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.: (If applicable, enter exempt in the license number line.) Bus. Tel. No.: Address: Alt. Tel. No.: *Per M.G.L. c. 147, s , 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: $

3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT # G TYPE OR PRINT CLEARLY JOBSITE ADDRESS OWNER S NAME OWNER ADDRESS TEL FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES FLOORS BSM BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND OWNER S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # SIGNATURE MP MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC # COMPANY NAME: ADDRESS CITY STATE ZIP TEL FAX CELL

4 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES THIS APPLICATION SERVES AS THE PERMIT Yes No _ FEE: $ PERMIT # _ PLAN REVIEW NOTES

5 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT # P TYPE OR PRINT CLEARLY JOBSITE ADDRESS OWNER S NAME OWNER ADDRESS TEL FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO FIXTURES FLOOR BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND OWNER S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER S NAME LICENSE # SIGNATURE MP JP CORPORATION # PARTNERSHIP # LLC # COMPANY NAME ADDRESS CITY STATE ZIP TEL FAX CELL

6 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES THIS APPLICATION SERVES AS THE PERMIT Yes No _ FEE: $ PERMIT # _ PLAN REVIEW NOTES