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HomeMy WebLinkAboutBLDE-22-001701 a AI Commonwealth of Official Use Only It% Massachusetts Permit No. BLDE-22-001701 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:9/24/2021 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) 40 BENJAMIN WAY Owner or Tenant GLAZIER DOUGLAS C JR Telephone No. Owner's Address GLAZIER JANE H, 20 COLELLA FARM ROAD, HOPKINTON, MA 01748 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: Wiring for addition(Roughed by others) Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires 12 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- ElNo.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets 25 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 9 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons 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 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 0 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 *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt.Tel.No.: 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 I ec)U - % 7/z Mat ell 6(12A n nonessaih.6/rilaoutehmeetio Official Use Only ', 2 ni I'ermitNv. 27.-� 1c ' 3 Occupancy and Fee Checked , �. , y ,,. BOARD OF FIRE PREVENTION REGULATIONS I ro7J 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: 9 J c a J j City or Town of: YA r r►-►ou;l� To the Inspector of Wirer: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 110 8 e el 1 a r,-11 n S.Ja 1 Owner or Tenant ; Telephone No. y Owner's Address <.:asp-y.` i Is this permit in conjunctionwith* pit? Yes 1 No 0 (Check App ropriate Box) PurPose of Buildint D Wc.(C,'.,.) an r Utility Authorization No. ill• Existing Service Amps I Volts Overhead 0 Undgrd❑ No.of Meters • New Service Amps I Volts Overhead 0 Undgrd 0 No.of Meters `: Number of Feeders turd;M Location and Nature of Proposed Ebectrleatl Work: .5 A co;T;o� o N Kt�.-r S'.L'e. o Po064_1�3 1tcSroor*S ALLwAY 1Aunc ry Clejer) C on c(thejollowin�table .air he waived by the l for of blurs. No.of Recessed L� 1.a No.of CAL-Snip.(Paddle)Fans Na.of alai Trasaf+ormers Kt4'A No.of Luminaire Outlets No.of Hot Tubs Generatars KVA -t' No.of Luminaires 5 Swimming Fool Al ❑ I ❑ Pie.:%d o y Units y L3glltln '� No.of I;t *Units e Oaf a 5 No.of Oat Burners FIRE ALARMS No.of Zones i. No.of�. No. Dbisaidell etection evices Na of Gas Burners l Li No.of flanges No.of Air Cond. TToOmi No.of Alerting Devices Dmt eat Pump Number'Tons I 'No. Se ,No.of Waste eers Totals: .._._._...____,...... _ Detection/ a _, Devices Noof Space/Aea Heating If C t 0 Other s Systems:*of_ Heating Appkances O of eviceso1stivnient No.of W Beaters K NO.of 1�No.or No. Devkes or Na B[y dry Butidults No.of Motors Total HP Tekeomnundeations N®i orporiroo or. OTHER; Attach slot detail fdr mad or as ruined by the Inspector of Wires. Estimated Value of Electrical Work: (When required by mullieiPel pul Y.) Work to art; Inspections to be requested in ice with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no pet nit for t1 the licensee provides prsaofof liabilityp�of electrical work may issue unless insurance including"completed operation"coverage twits substantial equivalent. The undersignet1 certifies that such r.. tirge is in force,and has exhibited proof ofsanic to the pew issuing office. CHECK ONE: INSURANCE BOND 0 OTHER 0 (Specify:) ems„wider the pains and es ofperjatiy,that time information en this alyiliendon.is Irmo and complete. FIRM NAME: D ckna ti .E'Lec-rr,c i.L C ,tee: �n LIC.NO.: a� ass q D a n,e L i Cc Sass. Signature al err►'eco. ru LIC.NO.: S J 6 5a E (frphcable,enter"exempt"in the t/cense comber tine Address: �C, ELK R�e1 13r Ivilcrc3Le6or .f1A C1a3ti6 .Ter.No. Co 6 q Y12r *Per M.O. ..c.147,s.57-6I,security work requires Department of Public „ AIL Tel.NoM.'S S S c - $i i' OWNER'S INSURANCE WAI ; I am aware that tie Licensee does r in.No. 5 S C(� -ly C> 3 7 3 required by law. By my signature below,I hereby waive this `insurance coverage ow efsrtal �,�,,,et requirement. I am the:(check one)©own+er ❑n�ur's agent. Telephone Noi L__________________ERMI ` FEE:$ 7S 1`+� The Commonwealth of Massachusetts =,r, t Department of Industrial Accidents w ='10= 1 Congress Street, Suite 100 V Boston,MA 02114-2017 ir r``'+.' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A !leant Information Please Print Leaibty Name (Business/Organization/Individual). — LL Address: 6 6 o City/State/Zip: 1"� ,c•�� L e k r p 2.6 Phone#: �- �58 6 Z Sai Are you an employer?Check the appropriate box: l-�am a employer with 2 Type of project(required): employees(full and/or part-time).* 7. 2.❑1 am a sole proprietor or partnership and have no employees working for me in ❑New construction any capacity.(No workers'comp.insurance required.) 8. 0 Remodeling 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required]t 1 ❑ ldin ion 4.❑I am a homeowner and will be hiring contractors to conduct all work on ro 1 (�1 Huilding addition ensure that all contractors either have workers'compensationP perry. I will proprietors with no employees. insurance or are sole 11.[]Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-co 12.[]Plumbing repairs or additions These sub-contractors have employees and have workers' fisted o a attached sheet comp.insurr ance i 13.0 Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MOIL c. 14 El 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'co t Homeowners who submit this affidavit indicatingycompensation policy information. Contractors that check this box must attached an additional sheet sall howing the name of the sk and then hire u b-contractors db-contractors and state we contractors must hetht er or not those entities have employers. If the sub-contractors have employees, indicatingew affidavit such. mp oyees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurancefor information my employees. Below is the policy and job site Insurance Company Name: 1 F 0. .j e r Policy#or Self-ins.Lie.#: t3 R — i z ci �, iLo 1 y a 1`1 Expiration Date:6_22 .a Job Site Address: `{C7 Bt,.r a M•,,1 00 Attach a copy of the workers'compensation policy declaration page(showing the policy number �expirahion 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 S250.00 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 rortifi:under the _ fe pains and penalties of perjury that the information provided above is true and correct Sinature: ` Phone#: Date: 3 1 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 Contact Person: Phone#: