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Home My WebLink AboutBLDE-23-003732 Commonwealth of Official Use Only 66Massachusetts Permit No. BLDE-23-003732 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:1/10/2023 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) 21 LITTLE DIPPER LN Owner or Tenant LECLAIR STEPHEN T Telephone No. Owner's Address LECLAIR BARBARA,40 HOLLY LN, BRIDGEWATER, MA 02324-2833 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 kitchen&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 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 Initiatine Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Ton No.of Waste Disposers Heat Pump Number Tons J KW No.of Self-Contained Totals: Detection/Alertine 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 Eauivalent No.of Water KW No.of No.of Ballasts Data Wiring: Heaters Siens No.of Devices or Eauivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Eauivalent 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 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. PERMIT FEE:$75.00 et‘,,eezdrz 011lz 14-1):4,,ri ,:-,. , rt �!► ,1:a4/t' '/ 3 �' . C i eoesmoi'swealih o,!/taaaar sue #a Official Use Only 1— A` ' ,nt ,ti++. sr iva Permit No. 2 2-3 7 J Z c *. ei, •€ Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.ll#)7,„ (have blank) id° APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC).527 Chill.12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1 /S/a)3 City or Town of: 7 QSMo u To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) nZ 1 L.;-r,-La_ ?(hr L A) .1;" Owner or Tenant o 6 L a c.Leu rP Telephone No. v Owner's Address .17,, ►e Is t in conjunction With a building permit? Yes No 0 (Chock Appropriate Box) Purpose of g Utility A*11$►rt5atian Rio. Existing Service f Oo Amps Po t ol''fo Volts Overhead Undgrd❑ No.of Meters I New Service Amps / Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Amy Location and Nature of Pry Electriati Works W-Q;,ai .r 4 1Z c ~A 1..[.eA W,Tr'h y, i,t 0.06 bet-c-hrber vl Completion of thefollawr 'rable�he waived by the Inspector of . vt go.� Recessed No.of Laminalres No.ofCeil.=Soap.(Paddle)Pans Transformers fcvA No.of Lumiaalre Outlets No.of Hot Tubs Generators KVA Above To- rils,ofL*mergeacy L g No.of Luminaires Swimming Pool Il d• u -find. 0 Bator Units No.of Receptacle Outlets . No.of OB Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners of Detection and Lditi>tfina Devices 1 ..,1 No.of Ranges No of Air Cond. Toonnss No.of Alerting Devices Waste "Heat Pump.Number Tons KW 'No.of Self-Contala ed No.of Totals ...... .._,._;De#ec#ou/AIer�11'�wlces No,of Dishwashers Space/Area Heating KW Local( n 0 tither No.of Dryers Beating Appliances KW �Sof or Equivalent No.of Water No.of No.of Heaters Signs Ballasts No.of Devices or ' ,kik* a No.Hydromassage Bathtubs No.of Motors Total HP 740.of Devices or :, r ,, ; OTHER: Attach additional detail ifdeshwd or as required by the Inspector of Wires. Estimated Value of:.tactical Work: (When required by municipal policy.) Work to Start: O Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C GE: 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 icov9tage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE siBOND 0 OTHER 0 (Specify:) I certify,air the pains and penalties epajttly,that the b fonnntlots an this alicadon is true and complete. FIR14MNAME p ar, t LecTr:c_ LLC LIC.NO.: I 4).r?5,q Licensee: 1)a n;c L e D t c t-sc..se. Signature obc.ru.Q e.&;4 u LIC.NO.: Si 6.5A£ (!f applkabte enter"exempt"in the license bomber line) $us.TeL No. 7 e i A5 8 71 70 Address: 6 ELK 1 r Pr 1`1 i d o Le 6 or c Pl A C cZ 3 Y C Alt.TeL No.:50 3 ( 9'? 318...5. *Per M.G.L.c. 147,s.57-61,security work rewires Department of Public Safety"S"License: Lie.No. 5 S C C - 0 0 1 3 7.3 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)Q owner 0 owner's agent. Signature Telephone No. PERMIT FEE:$ il 5 The Commonwealth of Massachusetts } 7� ' ` p/ Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 .. wwx.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Ele.ctricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/individual): 1 anA, ; � += l.ec;r, c L .C. Address: 6 b FL k 'Wu n 7 R City/State/Zip: 1"I; y Phone#: ,�c, 5 £ /2 '1 '5- Are you an employer?Cheek the appropriate box: Type of project(required): 1.[21 am a employer with 3 employees(full and/or part-time).* (--�1� 2.❑I am a sole proprietor or 7. L1 ew construction partnership and have no employees working for me in any capacity.(No workers'comp.insurance required.] 8. Remodeling 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t ❑Demolition 4. I am a homeowner and will be hiring contractors to conduct all work on ro 1 El Building addition ensure that all contractors either have workers compensationp I will proprietors with no employees. insurance or are sole 11.[�Electrical repairs or additions 5.❑I am a general contractor and I have hired the sub-co12.0 Plumbing repairs or additions These sub-contractors have employees and have workers' re listed on the attached sheet. comp,insurance.; 13.[�Roof repairs 6.ElWe are a corporaton and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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 the 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: Tr a V e e r Policy#or Self-ins.Lic.#: OR — t 3 `2 6 i R o i 1 a` `/ Expiration Date: 6 1 q 1 a 3 Job Site Address: ..,7I Z.iT rLL t)Q L City/ number ate/Zip: Y Attach a copy of the workers'compensation policy declaration page(showing the policynumb rrand expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to S1,500.00) 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. Si nature: 0,/ Date: , Phone#: .6 d R 6 7 7 !a 3 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. EIectrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: