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HomeMy WebLinkAboutBLDE-21-003515 Commonwealth of Massachusetts Official Use Only `"= •t Permit No. i=2`-3s-5s- . Department of fire Services l i ='Dr Occupancy and Fee Checked �� BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (leave blank) • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK . All work to be performed in accordance with the Massachusetts Electrical Code ,527 CMR 12.00 (PLEASE PRINT IN IRK OR TYPE ALL INFORMATION) Date: 1244 1 Z City or Town of: \I{cWIC01-1/4 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) b l M(6L4.61N,Z -A IL_ Owner or Tenant ' {o¢I/r,P wisctM RJ Telephone No. 11-4-Y,LO- t ut) Owner's Address Is this permit in conjunction with a building permit? Yes © No ❑ (Check Appropriate Box) Purpose of Building " Utility Authorization No. l.,risting Service Amps / Volts Overhead❑ Undgrd 0 No.of Meters New Service Amps / Volts Overhead El Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: -2ND Fwvit., 12-ax g LA(,vi-L-s Am, sow C 1%...$,_)C, i'"") Kw 151(fl40,4 Mugtf-t Wmc'J 1 Ftlubt Pt..-AA- MkSIba.'15tci bct- MA, ItaA)IOW IA 1 I12 Completion of the following table may be waived by the Inspector of Wires. Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans T .of TrNo. KVA Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ t o.of Emergency Lighting grnd grnd. Battery Units No.of Receptacle Outlets No.of 011 Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devic No.of Ranges No.of Air Cond. Total Tons o.o TonsAlerting Devices No.of Waste Disposers Heat Pump Number.Tons_.,_,KW __ No.of Self-Contained Totals: Detection/Alerting Devices • No.of Dishwashers Space/Area Heating KW . Local❑ Municipal ❑ Other Cos ;on 4 No.of Dryers Heating Appliances KW Security eCu o S • quivalent Data No.of Water KW No.of No.of Heaters Signs Ballasts ..of s eviceI' ',I, alent Na.Hydromassage Bathtubs No.of Motors Total HP • Te : .< s, txo 's' '•, N: ofDau y•r. �, OTHER: �y . , ^._, `, Attach additional detail if desired;a ,reed by t ` o , . • Estimated Value of Electrical Work: (When required by municipal policy. C,' ,, Work to Start t 16 'ya tions to bei', Inspections requested in accordance with MEC Rule 10, :r: �,..<<.k...1. : on INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electri .4;'.ork s4ay.. unless the licenseeprovidesproof of liability insurance including"completed operation"coverage or its substantial;equi :t ,t. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing off'i CHECK ONE: INSURANCE ® BOND 0 Oi'HE:R 0 (Specify.) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: M P(-c V L ' 9-- O/M,S k LAI-Gs-r0..1 Ct I'-3 LIC.NO.: 1139'))()-15 Licensee: Signature l9-"(ek.— 1.1,C2141- LIC.NO.: A, , (If applicable enter"exempt"in the license number line) Bus.TeL No.: 1A--Y/5 b V,�"t Address: Alt.Tel.No.: *Security System Contractor License required for this work;if applicable,enter the license number here: 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 on?)❑owner 0 owner's agent. Owner/Agent, Signature Telephone No. PERMIT FEE:$ EMAIL ADDRESS: ti • The Commonwealth of Massachusetts ll• -o =4 Department of Industrial Accidents • =• ,in= 1 Congress Street,Suite 100 ``-�;4``=-�y Boston,MA 02114-2017 -www.ma. gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Busing;ss/Organization/Individaal): Address: • City/State/Zip: Phone#: Are you-an employer?Check the appropriate box: Type of project(required): LO I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.01 am a sok proprietor orpartnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required] 9. 0 Demolition 101 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10[]Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property.I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance;# ' 6.0 We area corporation and its officers have exercisedtheir right of exemption per MGL c. 14.❑Other 152,11(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. ;Contractors that chetktbis box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees lithe sub-contractors have employees,they must provide their walkers'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: — Policy#or Self-ins,Lie.#: Expiration Date: 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 under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: 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#: