HomeMy WebLinkAboutBLDE-21-000556 Commonwealth,o/Massachusetts Official Use Only
- / ccyy�� cc77 Permit No. t2 2 -0 5s(o
=*► .-L a artment o .}ire Services
_ L- Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [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 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: t" -s—
City or Town of: - At-R. 7) `�„ 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) C,, 6. C 0 04_ j D 6 L'---- 1a/
Owner or Tenant y c'C i /1 6c,ii yi 0+2,� Telephone No,70 VP i -0,0 0 S"
Owner's Address J 4.L'j1,./ iZ� NI&Ri!-/ 4-ri-(_Fj 6-a.c, n-tA 02:7 (®0
Is this permit in conjunction with a building permit? Yes n No J (Check Appropriate Box)
Purpose of Building .5,.irs-'.-r &la- ,..,►,e Utility Authorization i. II
Existing Service Amps / Volts Overhead n Undgrd n etei/
New Service Amps % Volts Overhead[ - ndgr. 3
Number of Feeders and Ampacity tc?
A �
f
Location and Nature of Proposed Electrical Work: ,1/44),{i_i etL c. C.y2, 1
-50 t L.( L-- 1- Co i7 6 1 c-I CG 2 __ •
Completion of the following table may be waived by t •,;, sr, res.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of
Transformers KV•
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above ❑ In- ❑
No.of Luminaires Swimming Pool No.of Emergency Lighting
grnd. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
of Detection and
No.of Switches No.of Gas Burners No. Inittiating Devices
Tot
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
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water No.of No.of
Heaters KW Signs Ballasts Data Wiring:
g 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 wire..
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: --6------- .10 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
Ni)/1- undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
tQ, i p CHECK ONE: INSURANCE ,�] BOND ❑ OTHER ❑ (Specify:)
-4i I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME:7,/4 pi i 6,6 iiV5 t Z e-C•?12,4'C- LIC.NO.:/ 13 t _s g
Licensee: fc9-DD ,43, H /Co6r"65." Signature "�-,eei� LIC.NO.it,' �cys
P (If applicable,enter "exempt"in the license number line.) / Bus.Tel.No. G�
3 11Q Address: •C.7. c3 p1C /`7 �' O 2(.0 �S' r�'1 4�jl O �y
q *Per M.G.L.c. 147,s.57 61,security work requires Department of Publlic Safety"S"License: Alt.Tel.
cl•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)El owner ❑owner's agent.
Owner/Agent
Signature Telephone No. I PERMIT FEE: $ I
The Commonwealth of Massachusetts
f Department of Industrial Accidents
1
" t Office of Investigations
fir" riff
mow =;4 600 Washington Street
�`-b Boston,MA 02111
,Ej www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name (Business/Organization/Individual): -FA, N /6, GI•�G } EL ce--/C'
Address: PC- 3 f s`& C 'sT /
City/State/Zip:(3✓LC-eWli 014-02 C.5 3 Phone #: 6.-6 g g-3 7 C2- 95--
Are you an employer?Check the appropriate box: Type of project(required):
1.EI I am a employer with L 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. El New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. El Demolition
working for me in anycapacity. employees and have workers'
p tY 9. ❑ Building addition
[No workers'comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10. Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*My 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: t`/ 1 Y1 jvt cP 7 U r42---
Policy#or Self-ins.Lic.#: W C — � ' ,50e5 6i6"t:N Expiration Date: .2624 /.2 3
Job Site Address: 6 6" C 00L 106„ ZT i2P City/State/Zip:y( its ?i44
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 ains nd penalties of perjury that the information provided above is true and correct.
�Signature: .-A/ / Date: a.'`- 020
Phone#: V 3 G 2
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#: