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HomeMy WebLinkAboutBLDE-23-004097 ,� Commonwealth of official Use Only Massachusetts Permit No. BLDE-23-004097 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) 24 EASY ST Owner or Tenant SAND DOLLAR Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Ap¢repriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 Undgrd 0 ,• No.of Meters 7 New Service Amps Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Wiring for BDA. 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 NVA No.of Luminaire Outlets No.of Hot Tubs Generators i1 VA 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 Heat Pump Number , Tons KW No.of Self-Contained No.of Waste Disposers Totals: ,Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ 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 Signs 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 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: $80.00 4ECEiVED JAN a 2°23 i , \ C.,,,...44 0/ a.d.,...ti3 Official Use OPIY _ 1 c� c�� Permit No. 1 B►I I.D I., i T M E N I 1 2epartmet o f Jfr Sarui.:s� s <-. , i Occupancy and Fee Checked -\ BOARD OF FIRE PREVENTION REGULATIONS jRev. 1 0',; {leave bI >} APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK •-i All work to be performed in accordance with the Massachusetts Electrical Code(AMC).527 CMR 12.00 (PLEASE PRINT IN J K OR TYPE ALL INFC1RM417ON) Date: I )073 0?3 � City or Town of: 'ar,s-o a'�►n To the Inspector of Wires: V�g By this application the undersigned gives notice of his or her intention to perform the electrical work described below. iOLocation(Street&Number) y Ea SS I .S T t fin."t— R �' wner or Tenant SanC�1 C)OLLa.r CvST6rvt_S Telephone No. .k°. Owner's Address 2 S el Cr rc 4-r well-err.. l2 D 'f ro-%o..M " Is this permit In conjunction with a building permit? Yes ❑ No (Check Appropriate Box) 1�.f .; Purpose of Building C6n7Tct rTo r in a Y 5 Utility Authorization No. 0 Existing Service Amps / Volts Overhead 0 Undgrd No.of Meters pNew Service Amps / Volts Overhead C Undgrd E No.of Meters Number of Feeders and Amity Location and Nature ofProposed Electrical Work:L, W;r; 41 q o a. &BDA � - D;re ci- -,et C ' Gnni) 7 cr ) J ,.i Completion of the foilowinktable may be waived by the Inspector of Wires., No.of Total 1 i.i ;No.of Recessed Luminaires 1No.of Ceil.-Sump.(Paddle)Fans Transformers KVA No.of Hot Tubs Generators KVA �40.of Lrsminaire Outlets _= Above In- eta.at Lighting <:- No.of Luminaires swimming Pool mod, ❑ mod, 0 Batten'Uhitsmergencp n` No.of Receptacle Outlets No.of 011 Burners FIRE ALARMS iNo.of Zones Na.of Gas Garners No of lietection and .-- No.of Switches Initiating Devices e. 4 Tom No.of Alerting Devices 1 Li No.of Ranges lNa.of Air Cond. Tons Heat Pump Number tons_.._. KW No.of Self-Contained 4No.of Waste Disposers I Totals: --- Detection/AlerdnkDevices No.of Dishwashers SpaceArea Heating KW Local❑ 'cf:', on ❑ other p ,* No.of Dryers Beating Appliances KW .of Devices es or Equivalent No.of WaterNa.signsofHeiden Na.of Data Wiring: Ballasts No.of Devices or EV �ag: vakat Na g Telecommuans Bathtubs No.of Motors Total HP 1 No.of Devices or Equivalent OTHER: I 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 Stan:. • Inspections to be requested in accordance with IVEEC Rule I©.and upon c.-urnpietion. INSURANCE COVERAGE: Unless waived by the owner,no permit for Ise 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 cov a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certi.#,under the pains and penalties ofperjwy,that the infarrnation on this application is true and complete. FIRM NAME: D anc ' C Le.c;t-:c_ LLC LIC.NO.: J I a75 r`( Licensee: 1)C n,e[, E. i Lc Sc-s-,z Signature 1-;C,i;e. �✓.:.c,,-c LIC.NO.: .,3-/6-,,E. f1{applicable,enter"exempt"in the license number line.) Bus.Tel.No.: 7 e i PS$ 1 1 70 Address: h.. ELK R,.:, Th r /il t 6 c i_e b o M A c 9 3' 6 Alt.Tel.No.: -So S 6 9? t SS' '`Per Af.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. S S C Q - O G 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 mn the(check one)❑owner n owner's agent. Owner/AgentSignature Telephone No. PERMIT FEE:$ 'O- y / J se c7a.-i The Commonwealth of Massachusetts PDepartment of Industrial Accidents r;, t. ' b 1 Congress Street, Suite 100 Boston, ?ILA 02114-2017 www.mass.govidia \T orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Legibly Name (B.is:Tess/Organization/naividttai): -- L 1_ Address: 6 6 ,, -, D • CIty/State/Zi P:_ t-c\ ' ice! C . 3y; Phone ti: 9 Are you an employer?Check the appropriate box: l. t an,a employer with 3 Type of project(required): employees(full and/or part-time).* ; _ 2.Li am a sole proprietor or partnership and have no employees working for me in 7. L_1 ew con deIj uct3C n arty capacity.[No workers'comp.insurance required.] 8. Remodeling 3.`f i am a homeowner doing all work myself No workers'comp.insurance required_]' 9. Demolition • *. :am a homeowner and wil;be hiring contractors to conduct all work on my property. I will J ensure that all contractors either have worker mpeon ins ranee'co 10 ❑ Building addition proprietors with no em I or are sole 11.(�Electrical repairs or additions P ogees. 5.I ;I am a general contractor and I have hired the sub-co12. Plumbing repairs or additions These sr b contractors have employees cmp,i s i2� on the attached sheet p ogees and have workers' insurance.: 13.❑Roof repairs c. We are a corporat.on and its officers have exercised their right of exemption per MGL c. 14. Other {l 52,§I(Y'),and we have no employe es.[No workers'comp.insurance required.] *Any applicant that checks box;#1 must also fill out the section below showing their workers'corm-rmtion policy infonnation 7 Homeowners who submit this affidavit indicati. g they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Cormactors that check the box must attached an additional sheet showing the name of the sub-contractors and state whether or not employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. those entities have I am an employer that is providing workers'compensation insurance or o information. f my employees. Blow is the policy and job site Lnsurance Company Name: l r o Q. - r- Policy 4 or Self-ins.Lie.;r: 3_, `�F� ! �'O I 1 c `/a Expiration Date: % 3 Job Site Address: 41 ga SY S T Attach a copy of the workers' compensation policy declaration page(show ng thetpolicy number and expiration date . Failure to secure coverage as required under MGL c. 152 1 violation s a , ) and/or one-year imprisonment,as well as civil penalties in the foi-rn of STOP WORK ORDER and a by afine of up to$250.00 day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance.00 a coverage verification, T do hereby ,.ai�. etunder the pains and penalties of perjury that the information provided above as true and correct Signature: o 1 - Date: 1 473 3 Phone Official use only. Do not write in this area, to be completer/by city or town official City or Town:_ Permit/License l Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. EIectrical Inspector 5.plumbing Inspector 6. Other Contact Person• — Phone T: