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Home My WebLink AboutBLDE-23-000271 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 tg$, •:5 Boston, MA 02114-2017 www.niass.gov/dia i••• Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/individual): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with employees(full and/or part-time).* 7. E New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. ti Remodeling any capacity.[No workers'comp. insurance required.) 9. C Demolition 3.[1 I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 10 — Building addition 4.E I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.[]Other 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy informationt , 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-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: Policy#or Self-ins.Lic.#: Expiration Date: 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 of perjury that the information provided above is true and correct Signature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official. Permit/License# City or Town: one): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Issuing Authority(circle 6.Other Phone#: Contact Person: Commonwealth of Official Use Only i-- ,� Massachusetts Permit No. BLDE-23-000271 +� ,`? 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:7/18/2022 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) 96 STANDISH WAY Owner or Tenant LIBERTY LINDA J TRS Telephone No. Owner's Address LIBERTY WYNSOR C TRS, 96 STANDISH WAY,WEST YARMOUTH, MA 02673 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 , \[)\_ ' .of Mitt 10' ^``1CV New Service Amps Volts Overhead 0 Undgrd 0 c, A` I 17 Number of Feeders and Ampacity 0 "iv .int„. Location and Nature of Proposed Electrical Work: Install generator 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 1 KVA 24 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 Tons No.of Waste Disposers Heat Pump Number Tons , KW No.of Self-Contained Totals: Detection/Alertine Devices No.of Dishwashers Space/Area Heating KW Local 0 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 pedmy,that the information on this application is true and complete. FIRM NAME: Licensee: Signature LIC.NO.: (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address: 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: $50.00 RECEiVED _ o ealth 0,1 Mamtschuaefts Official Use Only 1 �, `� JUL 18 2022 �y` �ry1 ( Permit No. t.2-3 0 Z7 ` iro Service6 t; Occupancy and Fee Checked u1l_c� A ` REVENTION REGULATIONS Rev. 1/07] leave blank C.I APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION)p City or Town of: Y Date: /8 �� )') (�"1 To the Inspector of Wires: i By this application the undersigned gives notice of his or her intentioni1 to perform the electrical work described below. 1-- Location(Street&Number) / S A'A/"O IS 14 0 A Owner or Tenant 5o )7 r, QJ J Telephone No. 5 '.73 7-/$ / ' Owner's Address y6 5� O h' iS la l, (.3 y . LJ 1/& It ni o 1) 7-4 �? a l Q Z•6 ?3 Is this permit in conjunction with a building permit? Yes 11 No j (Check Appropriate Box) Purpose of Building gt5 06r/ /A/ Utility Authorization No. 'k. Existing Service 2.p0 Amps / ?Zd Volts Overhead PI Undgrd n No.of Meters / New Service Amps / Volts Overhead❑ Undgrd C No.of Meters 2 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 8,,A G r, hi a it,9 1 a OZ. Completion of the followingjable 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 l// 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 No.of Zones of No.of Switches No.of Gas Burners No. InDetection and nitiating Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices No.of Waste Disposers Heat PumpTotals Number„ Tons KW No.of Self-Contained p "" ' "" "'""' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ri Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts 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. Estimated Value of Electrical Work: 7// DOD. vd (When required by municipal policy.) Work to Start: 17 1 7 -zv Inspec4ions 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 cove age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER 0 (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: / ` ,�� LIC.NO.: 1 2- G/4. 6 Licensee: (A y/✓5I I'L- C, h-1 cb(0 dU y Signature (�e,, vt �` C.NO.: l 3 `� +'� (If applicable,enter/ exempt"in the 4icense jrumber lii(5J (J u5.TeL NO.: o g 7 3`f -lst7/� Address: 16 J j ply d ti 5 l" l� ti`� w' v` o u I i ff�i Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires apartment of Public Safety"s"License: Lie,No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature bel w,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agentl� `®S +7 1 _13 PERMIT FEE: $ Signature ` Telephone No.