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Home My WebLink AboutBLDE-22-004512 ‘ w Commonwealth of Official Use Only c` Massachusetts Permit No. BLDE-22-004512 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.1/07] 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:2/14/2022 City or Town of: YARMOUTH 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) 53 WILLIAMS RD Owner or Tenant Robert Mineo Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 Undgrd 0 No.of Meters New Service Amps Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Remodel kitchen& 1/2 bath room. 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 Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting grnd. grnd. 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. To No.of Alerting 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 0 Municipal 0 Other: Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Ballasts Data Wiring: Heaters Signs 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: Inspection 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. p / CHECK ONE:INSURANCE 0 BOND 0 OTHER 0 (Specify:) '78l- g�. G t 7o I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: DANIEL E DICESARE Licensee: Daniel E Dicesare Signature LIC.NO.: 21275 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:66 ELK RUN, MIDDLEBORO MA 023463065 Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: OWNER'S INSURANCE WAIVER:I am aware that the License does not have the liability insurance coverage normally required by law.But my signature below,I hereby waive this requirement.I am the(check one) 0 owner 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $75.00 Q )-ittt F((c Cwt glaiS l.,.orssrstonsvtJh oil!/loaaaciuseeks Official Use Only '' {� Permit No. ‘ .7-;--t —LIS( d � �lii _;� c7 .�spatmraf o/�Jiwr&Pvrtsd Occupancy and Fee Checked iBOARD OF FIRE PREVENTION REGULATIONS , v. 1/07] leave blank i 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: a?/9/.2a City or Town of: YA r/In es u ri. 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) .<-3 w;L e;e,v.5' 2v �' Owner or Tenant Ro b e r•r Nil AI es7 Telephone No. Owner's Address Sn elle dIs this permit in conjunction with a building permit? Yes ig No 0 (Cheek Appropriate Box) Parpose of Building L c Ead6; Y Utility Aut)horizadon No. Existing Service Amps / Volts Overhead❑ Undgrd 0 No.of Meters New Service _ Amps l Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Anspaty "-'1 Locatien and Nature of Proposed Elect ileal Work: FL t cm ti'c.a.'. W co r le i n 4 ,se nv o u qTe c1 i `/_ '`ei7`eAe,, an .?ATA (tang'<eric in Completion oftheolknvi rg i rble gray be waived by the bSeeeioe of Wires. 1 No.of Recessed Luminaires No.of Cdr. - -(Fendi}Fame No KVA No.of Lu mluatre Outlets No.of Hot Tubs Generators KVA I44).ni.Lummairen swimming Pao/'Above In- No.of imrerrgeacy Lighting grad. ❑ end. Q-Battery Emits :- No.of Receptacle ole Outlets No.of 011 Burners FIRE ALARMS No.of Zones n and --- No,of Switches No.of Gas Burners No.of Initiating Devices Total l V No.of Ranges No.of Air Cond. Togs No.of Alerting Devices No.ofwaste Disposers meatPump Number Tons KW_..__No.of Self-Contai�ted Totsta: ..w. ._.._._.�.JIAL_KW____ Detee:�an/AItn�Derkes No.of Dishwashers Space/Area Heating KW Local'Q coolie:don 0 Other No.of Dryers Beatlng APpliaacesKW S rils` '' No.of air Eft No.of WaterWo.of Ballasts WO. Ids KW ssignsy No 0 T7.`.... :,, •'.1,i. ..:,No.Hydromassage Bathtubs !No.of Motors Total HP \`V,.: .ce f , t No.of ,�Da:vless or Eomv OTHER: Attach additional detail rsksired or as required by the Inspector oj-Wires. Estimated Value of ' Work: (When required,by mutucipat policy.) Work to Start: Inspections to be requeded in accordance with MEC Rule 10,and upon completion. INSURANCE C Ei 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 CatifieS that such eoltage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEND [❑ OTHER 0 (Specify:) I certifr,wider the pains and penalties of palmy,that the information on dein application is true and complete. FIRM NAME: D 0.,-,e 3 €L e c-r-r,c_ L.L C LIC..NO.: e3 I .) 5 4 Licensee flan;el t '173 i Ce sels� Signature 0c3,ns,:1'n eh;4':apru LIC.NO.: SI 6 52i E (If applicable,erne "exempt"in the license murrber line.) , Bus.Tel.No.: 7?/ RS 8 9/70 Address: �F, ELK Rvr 1'i r CA1 c\a Le b o rc PIA Q�3 4 , Alt.Tel.No.:540 g h 9'/ l3 i 85 *Per M.G.L.e. 147,s.57.61,security work requires Department of Public Safety"S"License: Lic.No. S S C 0- O O 1 3?3 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 tequiremant. I am the(check one)0 owner 0 owner's agent. SiOwnegnature ged Sa Telephone No. PERMIT FEE:$ 7.4-- ' The Commonwealth of Massachusetts Department of Industrial Accidents _::mo_ 1 Congress Street, Suite 100 { Boston, MA 02114-2017 ` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Lesibly Name (Business/Organizationflndividual): fl (an A 1 F. Le c r: G L L C. Address: 6 6 FLK "Ru "0 R City/State/Zip: 1`'l ;c)c. L e X16 r-0 /t/ 3X35'6 Phone#: -5 0 8 6 9 /. 8 l 8 g Are you an employer?Check the appropriate box: Type of project(required): 1.2/1 am a employer with i. employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in. B. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myselft 9. CI Demolition ys [No workers'comp.insurance required} 10 ❑Building addition 4"0I 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. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance? 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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. ;Contractors 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: 1 r o. vel.e.r .5 Policy#or Self-ins.Lic.—�#: OJT 1 3< i 6 R o t — I — `/vZ Expiration Date: (, / q I a a Job Site Address: /.5 LSI 1.Li ct rn eRp City/State/Zip: YAmo.ri% Al A 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 herebycertifyunder thepains andpenalties oec f perjury that the information provided above is true and correct. Signature: catinjt ,S; Date: .2/ Q/020 Phone#: gyp g 6 9? ' 1 g 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#: