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HomeMy WebLinkAboutBLDE-23-000645 ck0 Commonwealth of Official Use Only � � Massachusetts Permit No. BLDE-23-000645 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.1/071 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:8/8/2022 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) 32 DAVIS RD Owner or Tenant LINDA SAVITSKY 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 ❑ Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Kitchen remodel 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. Total No.of Alerting Devices Ton 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. CHECK ONE:INSURANCE 0 BOND ❑ OTHER 0 (Specify:) 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. I PERMIT FEE:$75.00 L, e(0(t-w tte.., qAJ)4 - ci/' . - RECEIVED gat Use Only�" k UGpg 2422 Permit No. -�� DIN DEPART . , :CARD OF E PREVE;NTION REGULATIONS Occupancy1/44 and Fee Checked �'��'�� have blank j APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Niassachusetts Electrical Code(MEC),527 CIVIR 12.00 (PLEASE PRINT IN INK OR TYPE ALL ORM IION) Date: $l S l a a City or Town of: Yarn.oash 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 a t)o ui s R D Owner or-Tenant 1,�nda. S a.u:TS it y Telephone No. �, Owner's Address .Sarno t� Is this permit hs conjunction a building pertnit? Yea [ No 0 (Clerk Appropriate Box) Purpose of Building Si�vq L *F-tt.s.ulY Utility Authorization No, Existing Service Amps / Volts Overhead 0 Undgrd D No.of Meters New Servile r nd Amy / Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders __aat ;�i y Location and Nature of Proposed Electrical Work: ‘,,,,j; ik m3in 4 12cri+orStt.a /41rrh,i, vl Completion f thefollowingtable may be waived by the Inspector of Wires. No.of Recessed I�inaires No.of Cell-Snap.(Paddle)Fans To. ,mil Z. TransformersI'VA No.of Laire Outlets No.of Hot Tate Generators KVA 4t. AbNo.s Swimming Pool D ,traits grnd. Ind- Li gNO.ot a acy lighting "Zr: No.of Reaeptade Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners 'No.oL Detection inithang Devand ices S J No.off : .No.of Air Cond. ftle el' Tons No.of A Devices No.of Whets Heat Pump Number'Tons , — `D a ni Totals: '� .i-.' alertigtneviees No.of Dishwashers SpacelArea Heating KW Local lifunicipel e 0 Other Na oft Imes Hatt Appliances KW .* No.of Wttdter No of or Frt# Ivatent violNo.of No. of Dots Vfiiirlt ; S No of nevtcesr ' No.Hydromaaesge.Bathtubs No.of Motors Total HP Noi of Devices or Egalw � , OTHER Attach addition atdetail Vdeshied or as required by the Inspector of Wires. Estimated Value of B Work: (When /tea �����.> Work to ' 5 c,1 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURAf4CE COVERAGE: Listless waived by the owner,no permit fir the performance of electrical work may issue unless the licensee proves proof of liability insurance including"cad operation"cov eiagr or its substantial+equivaiern. The undeasig ed certifies that such is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE S. BOND 0 OTHER 0 (Specify:) I cerrifr'striderthepains and penalties ofparjwy,that the;inf trmadon on this application is true and complete. FIR14M NAME: .D an c, D £Le cTr c. L.C LIC.NO.: I a'2,5 A ari,c L t D is Ce.Sc re Signature aC id,yuS nob, LIC.NO.: (If applicable,enter Wit"in the license number line.) ' 'i 6.'Sa Address: (C ELK .R�r 'CN r jM+ ,1 i to 6 0�'c PIA c�a 3 ti 6 Buss.TeL No.: �$] 6I�$ g l` ,5 *Per M.G.L.c. 147,s.57-f:2,security work „ Alt.Tel.No.: 'S©$ E�9 0 8 t 3 7 Department of Safety"S License: Lic.No. S S c d- 4 Q t 3?3 OWNER'INSURANCE WARIER: I am aware that the Licensee does not have the liability required by law. By my signature below,Iwaive thisinsuranceoa coverage normally (marl hereby requirement. I am the(check cute}Downer 0 owner's agent. Signature Telephone No. 1 PERMIT FEE:a 1 Gay The Commonwealth of Massachusetts Department of Industrial Accidents 'SEW, 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print I.ea•ibly Name (Business/Organization/Individual): f) an A V Le r—r -:C. L L C. Address: 6 (, F L K "Ru r D R City/State/Zip: /1 c.j L e L,a r-o /-1 A ®a3`/6 Phone#: ..S 0 8 6 9 7 8 j S 5- Are you an employer?Check the appropriate box: Type of project(required): 1.�1 am a employer with employees(full and/or part-time).* 7. [New construction 2.0 any ama sole proprietor or partnership and have no employees working for me in $. 'Remodeling capacity.[No workers'camp.insurance required.] 3. I am a homeowner doingall work myself t 9. ❑Demolition ❑ ys [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on mY property. I will 10 ❑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.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.; 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MM.,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. ;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: r ex V e j e r Policy#or Self-ins.Lic.#: U 13 — j 3 9 5 j R O l — I`f — y a Expiration Date: 6 f R / c� Job Site Address: 3 pZ I�QVi 5 'O City/State/Zip: YW wto.tti+ !ti'tA 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: a121 (1_,, ; ( t4 Date: liVic2 Phone#: R (zJ'7 R 1 g fi 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#: