HomeMy WebLinkAboutBlde-20-000176 (2) _ Commonwealth.o//dladdachadettd Official Use Only
Ai1----�I Permit No. v ( 16_
c cc77
mil_ - T epartment o/. ire Serviced
-%----EARL C Occupancy and Fee Checked _
BOARD OF FIRE PREVENTION REGULATIONS ev.1/0
(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: —T /q / 19
City or Town of: Yu(rna/4h 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) I9 6I d Cedar /anp_, SoVTk ansel1A 0�'6G 11
Owner or Tenant Zell n no ph Imp 4 Telephone No.SQ'1.9 a 1 al 1 S'
Owner's Address me
Is this permit in I conjunction withha building permit? Yes n No, (Check Appropriate Box)
Purpose o;'Building �b eL lrVL14 Utility Authorization No.
Existing Service Amps J / Volts Overhead n Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters __
Number of Feeders and Ampacity I
Location and Nature of Proposed Electrical Work: f V c-1-I e NReeln 4- Amy y 1 V.s M l 1411 o✓1
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Sus (Paddle)Fans No.ofTotal
P Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of.Luminaires Above In- No.of Emergency Lighting
• Swimming Pool grnd. ❑ grnd. 0 Battery Units
No.of Receptacle Outlets No.of Oil Burners 'FIRE ALARMS No.of Zones
and
No.of Switches No.of Gas Burners No.I
Innitiatinngg Detection Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: '"" Detection/Alerting Devices
No.of Dishwashers Space/Area HeatingKW Local 0 Municipal ❑ Other
P Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW Signs Ballasts No.of Devices or Equivalent
No.Ilydromassage Bathtubs No.of Motors Total HP Telecommunications N ceorq Wiring:l
No.of Devices 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.
O INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
o 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.
Q" CD .+- CHECK ONE: INSURANCE [V1 BOND 0 OTHER 0 (Specify:)
is) o • I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
- V FIRM NA1A: g`- [t)III) Loo pi it,in t v(o 6- ei I to . LIC.NO.. i5 i Cs
Licensee: K.,t�-ff(LO M Ga10 Signature Cite LIC.NO.:c9/82
(If applicable,enter"exenu t' in the license number line.) Bus.Tel.No.;�i v8'3 qy'-7'7 lcS
Address: 1 SLg,�f71-OD!U GlfLt. 5Utttf( ii /y1U�T�t AM' �Jyb�_ Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-61,security world 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:$
ACCOUNTSPAYABLE@EFWINSLQW.COM I
U 1
w;,
The Commonwealth of Massachusetts
i� -, 1� !l, Department of Industrial Accidents
i�i 1 Congress Street,Suite 100
4. __ { Boston,MA 02114-2017
s� " www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):E F WINSLOW PLUMBING HEATING CO., INC
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778
Are you an employer?Check the appropriate box:
Type of project(required):
1.Q I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction
2.0I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
3.0I am a homeowner doing all work myself.[No workers'comp.insurance required]t
9. 0 Demolition
4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 D Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0ItOof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.['Other
152,§1(4),and we have no employees.[No workers'comp.insurance required]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Policy#or Self-ins.Lie.#:1909A Expiration Date:01/01/2020
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required,under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify and a pars nd pen lties of perjury that the information provided above is true and correct.
%
Si nature: — Date:
Phone#:508-394-7778
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: