HomeMy WebLinkAboutBLDE-22-001704 Commonwealth of Official Use Only
MassachusettsPermit No. BLDE-22-001704
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee P Y 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)
City or Town of: YARMOUTH Date: 021
To Inspector of
By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Wires:
Location(Street&Number) 340 HIGGINS CROWELL RD
Owner or Tenant TOWN OF YARMOUTH
Owner's Address 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4463 Telephone No.
Is this permit in conjunction with a building permit?
Purpose of Building Yes 0 No 0 (Check Appropriate Box)
Existing Service Utility Authorization No.
Amps Volts Overhead 0 Undgrd 0 No.of Meters
New Service
200 Amps Volts Overhead 0 Undgrd RI No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Wirin• of buildin• as re.uire
A
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
Tran for e Total
KVA
No.of Luminaire Outlets No.of Hot Tubs
Generators KVA
No.of Luminaires 53 SwimmingPool Above In-
rnd. ❑ rnd. ❑ No.of Emergency Lighting
No.of Receptacle Outlets 5 :atter nits
No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches 12 No.of Gas Burners
No.of Detection and
No.of Ranges Initiatin. D•vi e
No.of Air Cond. Total
To No.of Alerting Devices
Heat Pump Number KW No.of Self-Contained
No.of Waste Disposers
Totals:
No.of Dishwashers D•t•ctio Al•rtin' i evic•
Space/Area Heating KW Local 0 Municipal
No.of Dryers onn ction 0
Other:
Heating Appliances KW Security Systems:*
No.of Water KW No,of o.of Devices or E•uivalent
H•atees No.of Ballasts Data Wiring:
i.ns
No.Hydromassage Bathtubs No.of Devic• i r E, .ival•nt
No.of Motors Total HP Telecommunications Wiring:
OTHER: o. If D•vi es or E i u'val•nt
Estimated Value of Electrical Work: Attach additional detail if desired,or as required by the Inspector of Wires.
Work to start: (When required by municipal policy.)
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.
CHECK ONE:INSURANCE 0 BOND 0
OTHER I certify,under the pains and penalties operjury,that the information on on this applicationis true and complete.
FIRM NAME: DANIEL E DICESA E
Licensee: Daniel E Dicesare
(If applicable,enter"exempt"in the license number line.) Signature Tel. NO.: 21275
Address:66 ELK RUN, MIDDLEBORO MA 023463065 Bus.Tel.No.:
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.
Signature
Telephone No.
PERMIT FEE:$0.00
6mmon40141144
aaaachneetti Official Use only
# .
t ' PY and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS .11(}7j leave titanic
APPLICATION FOR PERMIT TO PE
All �,be performed inRFt3RM ELECTRICAL WORK,
with the Massachusetts Electrical Code(MEC),527 CMR 12M0
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7/0207/'/
City or Town of: YA r moues, To the Inspector of Wires:
By this application the tmdersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 33/0 h44inS _C ry wetG ?D
; Owner or Teat
- Telephone No.
of Owner's Address Y4 rr.,b o-rh tPot,a `pc p r
i� Is this permit in+ unction withaE 0 (Check
ParpogieofBa#l:Itn permit? Yes No Appropriate Box)
g Ur L;Ty hu Kehl A.1 q Utility Androx nation Nes,
Existing Service Amps / Volts Overhead❑ Uadgrd 0 No.of Meters
New Service (_G Amps /Jo 11OS Volts Overhead 0 U
d E. No.of Meters 1
Number of Feeders and
and Nature of Proposed Electrical Work: -.O j, c
07.
�. .. .IL1$) g.i �fi�A 1TS'(Jr1 dUTSu'QtLi �ntlFiTti R� � � �GJtt. uT�.CtT�/ b�,cc�,N9
. k-r ir) F��c4 51(41j, iTP_tic-s l_7OCS a,,,® $v/'te. // �r�
Ctli e ngm eft lowutktabte►a y tea waned by the! o Wires. ' 9c No.of No.ofCeiL-Snap.(P )Fans Trvf vial rmers 4
es OutletsZ
No.of Hot Tubs ,Generators KVA y
No.of Lam
Na of L Sslmmieg Pool Q —lj
No.of cyy Lightin
grad. land. Battery Units
',• No.
of Receptacle.Outlets No.of 011 Burners FIRE AI.AR14S No.of Zones o
• No.of S No,of Gas Barriers 'No.of Detection Devices o.,
Total p
t
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices q
No.of Waste mF No.ofSdf Contained
NumberToas_.._ KW 1
No.of Spaee/Area Heating I(W0 Mun
No.of Diryesit Local C'onnectioa 0 Other a
Remiss Appliances •, o
No ofWater , : No.of KWNa.of +or Equivalent
}haters ' No.ofDuo
Signs Ballasts NofDevkes or ',
'I'No.Il hubs No.of Motors Total HP or " ; ,
Na al Eon?" 13
LD
Est Value of Electrical WorksAttach a> d or as required by the tirspecter of Trim
s.
Work to Strut: 9'/301a t (When required by municipal policy.)
Inspections to be requested in accordance with MEC Rule 10,and upon completion,
!INSURANCE C E'ItAGE: Unless waived by the owner,no permit for the. a rfortnance of Chcirical work may issue unless
the licensee pcovides morel liability insuranceinc
� ��$"'completed operation"d coverage or#is substantial equivalent. The
is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 3 BOND 0 OTHER 0 (SPecify:)
/cosi&under the pains and penaltksofperftry,that tsilt a .
NAME: �t►rns�dO/r on this n b true and complete.FIRM c&. £'Let-trot LLC LIC.NO.: a I a?-5 4
Licensee: `)a(NI e.L £ i Ce.sass Signature o, Q.ra d'oCl;a UC.NO.: S'I 6:',3t E
afapplicaltie,enter" r"(�Mille ikense number`line.) ( /� C19,3(�/ N p .FM
Q Q J 7J
Address: �C, _ELK (Zcsrl Pt r '1 a Le 6 o r< Pi A i b Tel.eltoo.: So #; {f /s
*Per M.G.L.c. 147,s.57-61,security work requires t r nt of Public Alt.Tel.No.: �S g h - 0 3 7
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does notthe liabilityce: Lie.No. .S S C Ci - ya C4 13?3
required by law. By my signature below,I herebywaive thiskone)insurance coverage normally
OwnerJA requirement. I am the(check [�owner [�owner's agent.
Sivnetnre Telephone No. I PERMIT FEE:$ A/A f
The Commonwealth of Massachusetts
} it tit Department of Industrial Accidents
1 Congress Street, Suite 100
4 r� . Boston, MA 02114-2017
ow 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): f a A it ir Le r t': C L L.C-
Address: 6 6 F L K 11 r\ 0 R
City/State/Zip: PI;c. c) Lc\c-o /'1j 0 3y6 Phone#: _C> E 6 97 Sl $S
Are you an employer?Check the appropriate box: Type o project(required):
1. V/l am a employer with 1. employees(full and/or part-time).* 7. New construction
2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'camp.insurance required.] 9. ❑Demolition
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10 ❑Building addition
4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will
erasure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.D lam 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 i
I 14.❑Other
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c.
I 52,§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.
i 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. 'Q. L.Cr.<",
Policy#or Self-ins.Lic.#: �B 13 9 6 1 R 01 — 19 — `/a, Expiration Date: (:). I 1 ci a a
Job Site Address: 2 yd HI creciAs S CTcazct-L }�0 City/State/Zip: YArrexicrril M A_
Attach a copy of the worker -'1 mpensation 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.
` 4?3,hI
Signature: oaQ,�n.uUi� >� �� � ,cR 9.c. Date: /
Phone#: .....5 c) 6?'7 'R,) 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#: