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Home My WebLink AboutBLDE-23-000650 Commonwealth of Official Use Only R0.....-E Massachusetts Permit No. BLDE-23-000650 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: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) 597 FOREST RD Owner or Tenant TOWN OF YARMOUTH Telephone No. Owner's Address CENTRAL DUMP, 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4463 Is this permit in conjunction with a building permit? Yes O 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 CI Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: R/R exterior lights&emergency gas shut-off from building to replace damaged siding. Completion of the following table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above No.of Emergency Lighting No.of Luminaires 6 Swimming Pool grnd. ❑ In-grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS !No.of Zones No.of Detection and No.of Switches 1 No.of Gas Burners Initiating Devices No.of Air Cond. Total No.of Alerting Devices No.of Ranges Ton Heat Pump I Number I Tons KW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices 0 Municipal 0 Other: No.of Dishwashers Space/Area Heating KW LocalConnection Security Systems:* No.of Dryers Heating Appliances KW Np.of Devices or Euuivalent No.of Water KW No.of No.of Ballasts Data Wiring: Heaters Siens No.of Devices or Eauivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP 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 LIC.NO.: 21275 Licensee: Daniel E Dicesare Signature Bus.Tel.No.: (If applicable,enter"exempt"in the license number line.) Alt.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: 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: I $0.00 fall 1 q(4iY7- e-er RECEIVED 7 r/faaitsackm etta Official Use Q iy AUG8z *7 y/^ , }a. ta � Perrntt,ND,�./ �� C #t e BOARt? PAR 'V NTIOt REGULATIONS Rev. /aricy and Fee Checked I/07i 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 Ih'FOR TION} Date: 8/8/.?� City or Town of: y ar N,o uri, 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) 6 0 6 Fore sr To L Owner or Tenant Ton or Yar.,e jite, Telephone No. 4.)' Owner's Address 6 O 6 Fores.r Sp t Is this permit be COUjillicti011 with a building permit? Yes 0 No Q (Check Appropriate Box) Purpose of Building Utility Authorization No. di Existing Servke Amps / Volts Overhead E l Undgrd 0 No.of Meters • a New Service Amps / Volts Overhead E Undgrd El No.of Meters ` Number lof Feeders and Anspacity it Location aril Nature of Proposed Electrical Work: ,a e re t s. an a r'c $e-r 6 Ex re nto r b. L i q kr.$ Q.n d EA"(`'34.-,c./ 3 QS u r' Pp !.v r O -F 73 ct c C Go-,a Aa rt New.)-*SA• ez Contaetfon o(thefolowmeegtabk maybe waived by the Inspector of it' , No.ofRecessed Luminaires No.of Cd Tr Cell.-Snap.(Paddle)Fans Tr.nf. +VA ansiermers KYA. tZ No.of Unlash*O No.of Hot Tubs Generators KYA No.of Lm�aires wag Pool Abut ❑ In- ❑< Ito,tr Uidts acp Lighting and, rand. �IIsits. No.of Reeeptede Outlets No.of Oil Burners PM ALARMS No.of Zones nd No.of Switches „No.of Gas Burners No.ofIonnisfadni Deviises i U No.of 8�ges No.of Air Cond. Tons No.of Aug Devices Heat Pump Number Tons KW 'No.of� aiaed No.of Waste Totails: "' _. _ . _...._.. Detection/Alerting Devices 191uNo.of D washers Space(Area Heating KW Local'0 connection 0 Other No.of Dyers Appliances K4i� of SiecuritY _ or Equivalent No.of Verger No.of No.of Nut Hears ' Sig NoW�viees or �. No.Rydramussage Bathtubs ..No.of Motors . . Total HP 1W.of Devices or ', ,,. OTHER: Attach:additional detail iif desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work toStart:. , l 41a. Inspections to be requested in Ice with MEC Rule lo,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„cam operation"coverage or its substantial equivalent The undersigned certifies that such is io force,and has exhibited proof of same to the pewit issuing office. CHECK ONE: INSURANCE Erg BO 0 OTHER 0 (Specify:) I certify,.under the pains and penaides of f,that the informati I n on this application is true and complete. FIRM NAME: D cte,a F'Lec+-r',c. LLC LIC.NO.: a 1 a1 5 ALicensee: a n;e L i= T)i Ce.Sos . Signature 68,a nj eoU. LIC.NO.: �S'J 6 5a E (fapplicrrbie end 'exempt"in the license number line.) Bus.Tell,No.: 7 e i R5 R q 170 Address: . 66, ELK Rc:r\ !T1 r M i cad Le 6 o t-c /`1 A nee 3 y 6 Alt.Tel.No.: -So 8 h 9 7 S 18.. *Per M G.I.c. 147,s.5741,security work requires Department of Public Safety"S"License: Lie.No. $SC 0- OQ i 373 OWNER'S INSURANCE W i VER: I am aware that the Licensee does not haw the liability insurance coverage normally required by law. By my signature below,I hereby waive this tequireement. I am the(check one)0 owner Q owner's agent Owner/Agent I SignitUreTelephone No. P1l?'FEE:$ N A The Commonwealth of Massachusetts Department of Industrial Accidents e"e,%fl 1 Congress Street, Suite 100 ,= t= Boston,MA 02114-2017 wwwmass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aaalicant Information Please Print Lecibly Name (Business/Organization/Individual): I) a.c c i r:c-. L L tl Address: 6 F L 1< J r1 D R City/State/Zip: 1" + L(1n cs70 Mil O a3y b Phone#: .C> 3 .6 7.7 S) 8 5 Are you an employer?Cheek the appropriate box: • Type of project(required): 1.21 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'camp.insurance required.] 3. I am a homeowner doingall work myself 9. ❑Demolition ❑ ys [No workers'comp.insurance required} 4.❑I am a homeowner and will be hiring contractors to conduct all work on�'Pperty.ro I will 10 ❑Budding addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.[3 Plumbing repairs or additions 5.❑'f hm a getterll-contractoriand I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurances I3.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL 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 o. vg. Policy#or Self-ins.Lic.#: V J 1 S .6' 1 R p 1 " 1`l' - y a Expiration Date: 61 Job Site Address: City/State/Zip: 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 o f perjury that the information provided above is true and correct Signature: ea-a/anti1'£; -a-t� Date: Phone#: R 61? R i 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): L Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing]Inspector 6.Other Contact Person: Phone#: