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,.-^ e'A, dos` BOARD OF FIRE PREVENTION REGULATIONS [Rav,1/07] leaveblank
• APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(NEC), 27 CMR 12.00
(PLEASE PRINT IN INK OR r ALL r ORMATIOA) Date: 111 (—
City or Town of: 1 Ii To the Inspector of Wires:
• By this application the undersi: ed gives no'co of hi.or her intention to.er ormthe elec.ical work describedbeiow.
Mallon(Street&Number) . . t t fin if t. 02-6A I
Owner sor
Address
Tenant 54,eY; Co /C , , TelephoneNo,$
Owner's Address "Po .o X 66'i SIuJ4 artnAO ItyQ
Is this permit in conjunction with a building permit? Yes 0 No (CheckAppropriateBox)
PurpaseoYBullding DjilQ ` Utility AuthorizafionNa.
Existing Service Amps ' / Volts Overhead Unapt No.°Meters
New Service Amps / Volts Overhead 0 Undgrd❑ No.of Meters _-
Number of Feeders and Ampacity •
Location and Nature of Proposed Electrical Work: v( C- I Ii ( I.all
• _ Wire9
Com I Nonofthef bbl bewatveaoythe+To`a• - ....
No,of KVA
No.of Recessed Luminaires No,of Ceil.-Susp,(Paddle)Fans Transformers
No.of Luminaire Outlets No.of Hot Tubs •
Generators KVA
Abn- No.of Emergency Lip ig
No.of Luminaires Swimming Pool n ,ove I
d ❑ ,nd. ❑ Batter Units
No.of Receptacle Outlets. No.of OiiBurners FIRE ALARMS No.of Zones
No.of Detection and
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No.of Switches No.of Gas Burners Initiating Devices
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No.of Ranges Nb.of Air Cond. To yl No.of Alerting Devices
No.of WasteDis Disposers teat'ump `umter..,_-ons .,`I?_.• o.o elf--ontame.
_ p Totals: Detection/Aler4gDevices
Municipal ❑Other
No.ofDisfiwashers Space/Area Beating KW Local❑Connection
ecurt Systems:'r
No.of Dryers Heating Appliances KW No•of Devices orEIuivalent
No.of Water No.of No.of Data'Wiring:
Heaters KWNo.
Ballasts No.of Devices orE•nivalent
• e ecommunicattons' firingg:
lo.Hydrpmassag Bathtubs No.of Motors Total UP No.of Devices orE. rvalent
OTHER: •
Attach additional detail((desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When requited by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
Q INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
`f� the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,end has exhibited proof of same to the permit issuing office.
• ..f.-4CHECK ONE: INSURANCE Er BOND 0 OTHER 0 (Specify:)
and
' • I certify,under the pains andpenalties of perjury,that the information on this application Is true and complete.
Q FIRM NAME: ,F 0 IUSLou) 'GU. . Lo h H', , .... 'r 10-' , ' LIC.NO.: _3
✓ / / LIC.NO•:oO��l Sr �/ .
Licensee:�lC(� /1 W1(O Signature •
.. 03' `ty' �S
a' 0 • (If applicable,ent J' •,n 4"In the license ber line) ' Bus.Tel.No.
C.) O Address: - .L 4t /o/O t�Gta Salt t r ; ! r It !� t7 *•Alt Te].No.:�—
r' "Per M.O,L.c.147,s.57-61,security wor requires Department of Public Safety"S"License: Lio.No. _______----
O— OWNER'S INSURANCE WAIVER: I aro 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)0 owner ❑ov ner's a ent
Owner/Agent PERMITFEE:$
-' Signature Telephone No.
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't.c.,,,,
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.The Commonwealth oflaacuses •
t W. ari _Department of lndustrialAccidenls= 5
ti _RI fes s•
I Congress Street,Salle I00= rr
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-4,.L', Boston,111.4 021144017
Workers' wwwmasagov/dia :
Compensation Insurance Affidavit:general Businesses..
A,alicantInformation TO BEFABBWITI,aoP TTINGAUTHOBTTY,
Please Print Le.ib.
Business/OrganiyafzonName'E.F.
WINSLOW PLUMBING&HEATING CO.,INC
Address:8 REARDON CIRCLE
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City/State/Zip:SOUTH YARMOUTH,MA 02664.
ueyou anemployer?Check ftea t Phone#;608394'/776'
•0 Iamaemployerwith PP'oPriatabox:
Bu0 Rs Type(required):
or part-time).*
�emp]oyees(fulland/ 5. []Rafal
masoleproprietororpartnershpandhaveno 6 ]RestauranUBar/Batng&tablislunent
I a
employees working forme in any capacity, 7. Q Office and/or Sales(incl,real estate,auto,etc.) •
0 [No workers'comp.insurance required] 8.
We are a corporation and its officers have e 0 EnNon-profitn
. their right of exemption per c.152,§14), exerchave ised 9. fl0 Manrtaiament
0 noearano ianees [No workers'
ons insurancerequired? g '
10.[1 Manufactur n
with nc employees.[No workers' taffed by volunteers, •
11.0Otherh Cara
yepplicantl)tetchecksCOmP•iasurancareq.] 12,[]Other •
'
box •
#1 must also fill out the section below showing their
the
ce orae officers have exempted themselves,but the employees.ora
check box ill.
corporation hes atherw to peasetioapolicy iafomadon
P Yeas,aworkes'compensation policy is required and such an
tan employer thaiZs providingworkers'compensation
raneeCompanyName:ARROWMUTUALINSURANEMefornryemployees Below istkepolicy lnforrnafory
COMPANY
refs Address;23 COMMONWi
EALTH AVE
$tatelZ ; CHESTNUT HILL,MA 02467
y#or Self-ins.Lk.#1821A
:It a copy of the workers'compensat on policy dedal io
:etosecurecovera a requiredExprationDate:01/01/20
g as under Section 25An page
can lead to the'repopolicy num ofcrimer and expiration penaoties of •
p to$1,500secure coverage
end/or one-year imprisonment, ofMGL c.152 can lead to imposition criminal penalties of a
to$250.00 a day against the violator. as well as civil penalties in the form of a STOP WORK ORDER and atine
igations of the DIA for insurance Be advised that a copy of this statementmay be forwarded to the Office of
coverage verification,
ereby cera •
—�— .
:.: ena(ties o perjury that f p
ure: ry the ormatton rovidedabove lstrue and correct
508.394.7778 Date: .. / .
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dal use only, Do/Wine M this area,to be completed by city or town official
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or Town: •
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ugAuthorlty(tie one): Permit/License#
ardofHeaith 2.BuildingDe
her parfinent 3,City/Ton—Clerk 4.LicensingBoard 5.Selectmen's Office
tctPerson
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phone ii:
www.messgov/dia
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