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HomeMy WebLinkAboutBLDE-23-004098 Commonwealth of Official Use Only Sal Massachusetts Permit No. BLDE-23-004098 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:1/25/2023 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) 22 NIMBLE HILL DR Owner or Tenant RESIDENT Telephone No. Owner's Address CARNES KAREN E, 22 NIMBLE HILL DR,YARMOUTH PORT, MA 02675 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: Remodel bathroom 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 TotalTransformers 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 Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alertine Devices Space/Area HeatingLocal ❑ Municipal No.of Dishwashers P KW Connection ❑ Other: HeatingAppliances KW Security Systems:* No.of Dryers PP No.of Devices or Equivalent No.of Water KW No.of No.of Ballasts Data Wiring: Heaters Siens No.of Devices or Equivalent 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. required bymunicipal policy.) Estimated Value of Electrical Work: (Whenq p P y' 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.: o. 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. I PERMIT FEE: $50.00I G(41.t 6\4) a vat/ ,0 7/3 ) ( ( RECEIVED JAN 23 20 ct Use Only BUILDIN( Dc '' • ey. — ,� .L� Occupancy and Fee Checked 1 BOARD OF FIRE PREVENTION REGULATIONS .1/071 leave Wank ' c APPLICATION FOR PERMIT TO PERFORM' ELECTRICAL WORK in accordance with the Massachusetts Electrical Code(MEC).527 CMR 12.00 All arsulctfl be performed Dote: � �0�3 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) T o the Inspector 2ref Wires: City or Town of: Y arrvt o urrh the electrical work des below. - By this application the undersigned gives notice of his or her intention to perform Location(Street&Number) ,L 1 R • Telephone No. Owner or Tenant : kory Owner's A ddros 5 n 1_-tBe:) o) No u (Check Appropriate t� Is this permit is ccafn w�s building�' Authorization No. Purpose of Big '5+4 ct/< Utility Nfl.of Meters E� ServiceAmps I Volts Overhead 0 i3ndgrd El New Service Atolls / Volts Over❑ um..❑ No.of Meters Number of Feeders and A sad Nature of ProPosed. Work: ELe err.;ca 1.. (Jo rK i." a Qt.,v► L a bATtn ' Ov ti JSt i TG 7 the ... s;D Wires.ery�blK 4- t C .,,..,, :, the .flow ._ale_.,, waived >., 1 No.of Cdt.-Sesp..(Paddle)Fans Trausfarmen. KVA i. hto.of��: KVA No.ofHot Tubs Generators ev No.of Lunt Outlets r g r'It ' of Luminaires Swimming Pool .„. , a- 0 ildiis No.of Oil. FIRE:ALARMS No.of Zones -.� No.of Receptacle 'of a. ►"..'.�;� � ,: , No.of Switches No.of Gas Burners •F; r, • Devices t� No.ef'Rouges No.of Air Cond. Tons o.of Alerting Devices No.of Waste� , ons , �� . ,,r Totaler Detection/ ,,. ........ No.of Dishwashen Slum/Ares Heating KW Loral 0 Caien 0 other Hem AIrp KW No.of 3 or - , Dryers , No.o *ter , o wing: ,o' ` No.ofDorices or - -, No.Bydromassage Bath#!tllS... No.of Motors Total.HP No.of�or ., ,, ' , 1111111 ffl'FfER: Attach additional dot ii sf esi or as required by the tsar of Wires. (When es.) Estimeed�lalueofElectrical 4�orkrequired by muni Pulcewith.MEC Rule 2fl,and completion. Inspections to be requestedin work may Issue unless IWork toNSURANCE-COVERAGE: Start_______ Oahe performance of electrical INS�fitt�4NCE CLYtfiE'RAGE: Unless waived by the owner,no pert licensee liability insuranceincluding �operation"coverage or its substantial equivalent ivalett The the as undersigned suchas is in force,and proof of same to the petmit issuing office. CHECK ONE: INSURANCE GI BOND ❑ OTHER 0 (specify) true and cow I ram,a painsand pen oft ,rr� in a�st,��c.complete. 5 9 FIRM NAME: cznd r Lecrr;L Lt P P I.IC.NU.: Sf F_ Signature -� 9 a licensee: �ct;i,t L i� -s�' Bus.Tel.�ta.;_.�-`�i �'� 1� Afddr Address: exempt"in the license n mfber line.) �So Q ti 5? E 1$� 1 i_e 6 �' 6 Alt.Tel No. _n ' 1 S 3 Atida'ess. s t3` work rDepartment of Public Safety"S"License: Lie.No. .0..-0 *Per R' .c. s.57-61, I:arn aware that the Licensee does'not have the liability insurance coverage normally OWNER'S INSURANCE WhIVF1t: rerl�t, I am the(check onea wirier a OWOtr''S.'":irt. required by law. By my signaturebelow,I hereby waive this rPERMIT� :� �Q" pwnerlAgettt Telephone Ne. Sigma / ;NS f,e efri an • i • The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 • vormobr _• ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERM'i'FING AUTHORITY. Applicant Information Please Print Legibly Name (B-.isiness/Organiaa ion/Individual):_p G n r' i1 1- Le c ,--t-: C L L Address: 6 FL K r. R City/State/Zip: �`'� c5e� j -�: ,' G ay6 Phone#: G E 672 j S Are you an employer?Check the appropriate box: Type of project(required): I.2/1 am a employer with 3 employees(full and/or part-time).* ? I am a sole proprietor or partnership and have no employees �. ❑New constructer: working for or me.n 8. ©Remodeling any capacit y.jNo workers'comp. required.; am a homeowner doing all work myself 9. Q Demolition ys [No workers'comp.insurance require]t Lt.D I am a homeowner and will be hiring contractors to conduct all work on my property. I will I0 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 5.�1 I am e general contractor and I have hired the sub-contractors iisred on the attached sheet { 12. Plumbing repairs or add*,ions These sub-contractors have employees and have workers'comp.insurance.; I 13. Roof repairs f 6.D We are a corporaton and its officers have exercised their right 152,§i(4),and we have no employees. of exemption per MGL c. 14.E Other [No workers'comp.insurance recuired.1 *Any applicant that checks box i#1 must also fill out the section below showing their workers'compensation policy infrmaton. f Homeowners who submit thus affidavit indicating they are doing all work and then hire outside contractors must submit 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: rave L Policy#or Self-ins.Lic.#: l_)R — J j R O i — !`1 — y Expiration Date: b 1 job Site Address: e.10` Al;to b G ore City/State/Zip: l o Attach a copy of the workers' compensation policy declaration page(showing the policy numb nd 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties o f perjury that the information provided above is true and co;F■ect. Signature: oQ r, ( , Date: 1/073/02.3 Phone#: _$c s' 69-1 ' t g Official use only. Do not write in this area,to be completed by city or town officiaL City or Town:_ Permit/License 4 Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.-Plumbing Inspector 6.Other Phone#: Contact Person: