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HomeMy WebLinkAboutBLDE-23-004099 Commonwealth of Official Use Only %I.\ Massachusetts Permit No. BLDE-23-004099 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked 1Rev.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 'LEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:1/25/2023 To the Inspector of Wires: City or Town of: YARMOUTH ,y this application the undersigned gives notice of his or her intention to perform the electrical work described below. .ocation(Street&Number) 40 BENJAMIN WAY Telephone No. )wner or Tenant JAMES FITZGIBBONS )wner's Address Appropriate Box) s this permit in conjunction with a building permit? Yes 0 No 0 (Check Utility Authorization No. 'urpose of BuildingNo.of Meters F,xisting Service Amps Volts Overhead 0 Undgrd 0 1 Vew Service Amps Volts Overhead 0 Undgrd 0 No.of Meters number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Work in expanded kitchen. f Completion of the following table may be waived by the Inspector of Wires. No.of Total No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Recessed Luminaires KVA No.of Luminaire Outlets No.of Hot Tubs Generators Above ❑ In- ❑ No.of Emergency Lighting No.of Luminaires Swimming Pool grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiatine Devices Total No.of Alerting Devices No.of Ranges No.of Air Cond. Ton Heat Pump I Number I Tons KW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alertine Devices Local 0 Munici al No.of Dishwashers Space/Area Heating KW n is pion 0 Other: Security Systems:* No.of Dryers Heating Appliances KW No.of Devices or Equivalent NoNo.of No.of Ballasts Data Wiring: He Water KW Siens No.of Devices or Equivalent Heaters 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. f electrical work may issue unless INSURANCE COVERAGE:Unless waived by the owner, coverage e oermit mits substanr the tial al equance ivalent.alent The undersigned certifies that such covee licensee rage proof of liability insurance including"completed operation" g is in force,and has exhibited proof of same to the permit issuing office. S eci 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 Signature LIC.NO.: 21275 Licensee: Daniel E Dicesare Bus.Tel.No.: A(I 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 w a ri ity insurance 0 owner' en coverage normally required by law.But my s signature below,I hereby waive this requirement.I am the(check one) o t. Owner/Agent PERMIT FEE: $75.00 Telephone No. Signature avail (23 96P(Z3 ee RECEIVED J AN 2 3 iid cCi$i use Only Permit No. 0-3 -4099 B ButLo V i •-t ,.— fit `^` y and Fee Checked I Y. BOARD OF FIRE PREVENTION REGULATIONS .Il07) Leave been 1 c APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code NEC),527 CMR t2.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: l/e23/23 City or Town Of: Yarrr►,,,,sti 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) yD 9e i Sa.ni el 4 &'f V n,.� p,--,f:„ s Telephone No. Owner or Tenant Owner's Address ..5carrt c L No 0 (Cheek App>�e Box) � Is this permit is conjunction with s b Yes Purpose of Mating ..i nr L. F,n i L Y Utility Authorization No. Existing Service Amps l Volts Overhead 0-t Undgrd 0. No.of Meters New Service Amps / Volts Overhead D Undgrd.0'' .No.of Meters Number of Feeders and A Na"1 Location and tan of Proposed Flectrical Work: Eke.cert.;Ca L wort :n a- . EXQa.,ace) . K,rGhuo vl Cam M:a f the fallowinktabk may be waived by the{ er of Wires. vl No.of Total , Recessed of luminaires No.of CeIL-S .(Paddle)Fans ,rressfecoecs . KvA V. No.of Lumhudre Oudets No.of Hot Tubs Generators tors KVA Above In- - tto.m�iY L�tscusg No.or hires swimming Pool yam, 0 to 0 B y IIatits No.of lteueptade Outlets No.of Oil Burners FIRE.ALARMS No.of Zones No.of GasBurners 'No.of Detection and �. No.of SwitchesT"iti'tti'g Devices Total Plc.of Alert*1 t.'' No.of Ranges No.of Air Cond. Tons Heat Pump f Number Tans _;. KW ,__)o.of Seif-C�. Na.of Waste Disposers Totals: I I Detedion/ .-, ,. Dexiem No.of Dishwashers Space/Area Heating KW Local 0 In, fl -•a 0 Other Security,. No.of Dryers Beating Appliances KW Na.ofS=or Etadvaleat No.of Water W No. sof -Data Whiny. Heaters Signs Bob No.ofDevices or " T , No.Spd Bathtubs No.of Motors Total HP Ne.of l OTHER: Attach adttitional detail rdesb ed or at required by the Vim'of Wires. Estimated Value of Electrical Work: .. (When required by municipal policy.) Work to Start:. Inspections to be requested in accordance with MEC Rule lt),and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of decries!work may'issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent The undersigned certifies that such a is in force,and has exhibited proof ofsame to the permit issuing office. CHECK ONE: INSURANCE ler BOND 0 OTHER 0 (Specify:) I cenifr,ander the pains and p ofperjwy=that the lief r sarion on tlrs apf ilcadon.s true and complete. FIRM NAME: D are D €ze(1.-rr:c_ LLC LIC NO.: ,3I a?S A Licensee: ,an,e_I. i= t Ce See Signature eof ,e.,a LIC.NO.: SI 6'Cds E. (Ifapplicable.enter`exempt"in the license member line.) Bus.Tel.No.: 7 8 i SS$ 4 I?O Address: 6 ELK R,JrN tc Mic;6Lebor.o j� AA ©=-93'16 Alt.TELNo.: -So 3 h5? gi8s *Per M.G.L.c. 147,s.5741,security work requires Department of Public Safety"S"License: Lie.No. 5 SC C - 0()I 3 7 3 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)0 owner 0 owner's agent. Signature Telephone No. PERMIT FEE:$ 75- ;,,,vccriorls • The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, M4 02114-2017 •`� www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leziblv Name (Business/Organization/Individual): D a n c r r; C L L C Address: E: F t K R City/State/Zip: /t'1 c3e. Le\f 11/1 C. 3y6 Phone#: 5c 3 77 Are you an employer?Cheek the appropriate box: i II Type of project(required): 1.21 am a employer with 3 employees(full and/or part-time).* 7. I Retn delinconstructicn 2•�}I e proprietor or partnership and have no employees working for me in 8. ;L—+�" capacity.[No workers'comp.insurance required.] Remodeling 3.0 i am a homeowner doing all work myself[No workers'comp.insurance required.)t 9. ❑Demolition 4.D I am a homeowner and will be hiring contractors tractors to conduct all work on property. I will 10 ❑ Building addition ensure at all contractors either have workers'com proprietors with no employees. Peon insurance or are sole 11.0 Electrical repairs or additions 12.❑Plumbing repairs or additions 5.(E" I am a general contractor and I have hired the sub-contractors listed on the attached sheet These s -contractors have employees and have workers'comp.insurance? 13.❑Roof repairs ub 6.D We are a corporaton and its officers have exercised their right of exemption per MGL c. 14•El Other 52,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. y Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contactors 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 sire information. Insurance Company Name: j i- Q. L. Policy#or Self-ins.Lic.#: l 3 -- 3 9 6 ! R C?1 - /`t - `/ Expiration Date: 6/ I .a 3 Job Site Address: Yo Bon 34 W1.,r t waY City/State/Zip: Yarrr,o csik MA 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 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 certify under the pains and penalties o f perjury that the information provided above is true and correct. Signature: c-JQ.r e ,, , C'4„.cmt• Date: 1 la 3id 3 Phone#: ��Cj 6 7? 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): 1.Board of Health 2. Building Department 3.City/Town CIerk 4. Electrical Inspector 5.-Plumbing Inspector 6.Other Contact Person:—' Phone#: I