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HomeMy WebLinkAboutBLDE-23-000198 Commonwealth of Official Use Only Massachusetts Permit No. BLDE-23-000198 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:7/12/2022 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) 24 EASY ST Owner or Tenant Sand Dollar Customs Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (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: High level alarm for tight tank. 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 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/Alerting 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 Equivalent No.of Water KW No.of No.of Ballasts Data Wiring: Heaters Siens No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: 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 perjuly,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: $160.00 l " - 7t - cii rc-aoM ii- c' nt-nW4 c ' cp e ll/vvz FN itj (.2,„ Comason4vaafth oy i//cr cku�alfs Official Use Only `i 3� CI1D3O. 1/�, 1 , 2epa bent off Jiro Serviced C )i Occupancy and Fee Checked ' - - BOARD OF FIRE PREVENTION REGULATIONS v.l/47j leave blank 1 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: 7/7 42) City or Town of: YA r rvl oc/Th 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) o?() Fa_S y S T j Owner or Tenant 50."a (Nollc-r CvSrown 5 Tdephone No. wsil Owner's Address a2.5 1 artcc r ( )e 5-rear. 1) 0.n.•? 3 u Is this permit In conjunction with a building permit? Yes ❑ No Eff (Cheek Appropriate Box) Purpose of Building Tro.c'L 5 rn e-.., tpki. C� --, Utility Authorization No. Existing Service Amps / Volts Overhead E Undgrd❑ No.of Meters _ New Service Amps / Volts Overhead Undgrd❑ No.of Meters Number of Feeders and Ampacity ) Location and Nature of Proposed\\Ma. l Work: vui R; J q trF ( H LI h Le�/ Q(e r w, '4: roe a 4-1,nor C'"�rct;n TTgitr Tel•-,Jib (Tre.le), .^rsp neeticA ) vl J Completion of the following table Wray be w.ola+ed by the f or of Wires. No.of al 1,t1 No.of Recessed Luminaires No.of CelL-Snap.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators K%A Above In- No.of-Emergency Lighting st- •No.of Luminaires Swimming Pool ❑ ❑ � Y g grad:' pint. Battery Units No.of Receptacle Outlets No.of Burners FIRE ALARMS No.of Zones , o.of Detection and No.of Switches No.of Gas Burners Initiating Devices ..1 No.of Ranges No.of AirCond. Total No.of AlertingDevices Tons No.of Waste -Heat Pump Number Tons__ KW "No.of Self-Contained Totals: "" Detection/Alerting Devices No.of dashers ' Space/Area Heating KW Local❑ Municipal ❑ other Connection * No.of Dryers Heating Appliances KW Security Syysstteems: No..of vet::a,or .a:ent No.of Water 'No.of N ,of Data Wiring: Heaters Signs Bal<ash No.of Devices or Equivalent No.Hydroaaa*age Bathtubs No.of Motors Total HP �'I` of Devua Devices r Eon isg Na of Devices or Ectaivalent: OTHER: Attach final dvttril g desiried or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to S /l /„?,,1 Inspections to be requested in accordance with WC 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 a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE!BOND 0 OTHER 0 (Specify:) I certify,noder the pains and penalties ofpeajsry,that the Information on this application is true and complete. FIRM NAME: D a..-. D €L e c-r r;c U.C [AC.NO.: e3 i a")S A Licensee: 0 a(i e_I i= D i Cc Sc c(. Signature o8cr.n acid; cha LIC.NO.:• s/650,E Of applicable,enter"exempt"in the license number tine.) Bus.Tel.No.: 7 e i f?S$ 1170 Address: ELK 1:2,,,r1 IN MCdc Le6o jhA 0a3Y6 Alt.Tel.Na.: •Sog hV? f318 - *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. S SC o-CO Q 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)0 owner d owner's agent OwnerlAgeut Signature Telephone No. 1 PERMIT FEE:$ /60 _ The Commonwealth of Massachusetts =_ �1 Department of Industrial Accidents lel= 1 Congress Street,Suite 100 % �= Boston,MA 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 I eaibly Name(Business/Organization/Individual): fl a 1 V/e r -q-C L L C. Address: 66 ELK run DR City/State/Zio: ,„,710ih:ac .3y Phone#_ 0 5_ 4_77 j R s -- Are you an employer?Cheek the appropriate box: Type of project(required): .Efi am a employer with Z 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'comp.insurance required.] 3, I am a homeowner dolt all work myself t 9. ❑Demolition ❑ Syse [No workers'comp.insurance required.] • 4.0 I am a homeowner and will be hiring contractors to conduct all work on my PPanY•I will ro lU©building additionensure that all contractors either have workers'compensation insurance or are sole 11.141 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 These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.0 We are a corporation and as 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#1I must also fill out the section below showing their workers'compensation policy information 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 oldie sub-co,n.ar.turs 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.Let-' I Policy#or Self-ins.Lic.#: v R- j �'4 Fi I R O[- f' -y a Expiration Date: 6/ 9 /;Z a Job Site Address: v.,E c�,-5 City/State/Zip:2ip YArm 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 I do hereby cer tify underthe pains and penalties of perjury that the information provided above is true and correct Signature: oUcUru ', ,(,. -t, Date: 'V)/ Q Phone#: S 6 97 R I 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: