HomeMy WebLinkAboutElectrical Permit #12961-1 - Permits #12961-1 - 225 ABBOTT STREET 12/14/2015 ITV
Commonwealth of Massachusetts Official''Use Only
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Pennit No
Department of Fire Services
Occupancy and Fee Checked,
40
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BOARD FIREPREVENTIONREGULATIONS �. (leave blank)
APPLICATIONFOR PERMIT TO PERFORM ELECTRI CAL WORK
All word to be performed,in accordance with the Massachusetts Elec.Vtcal Code ), 27,C 12.00,
(PLEASE NN O TYPE ALL INFO O v
City or Town oh- NORTH AND,OVER To the p
�Mu f n d
or f Wires.-
By Us application the undersigned gives notice of his,or her intention to,perform, the electrical work described below.
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Location(Street&Number)
rioter "v ,i
45,
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Owner orTenant � �.� ,, Telephone .
w ' Address
bul"Iding,permit"? yels EL No (Cheek r*
- eUtififtyAuthorlization No.
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ExisfiIng ServiceAmps 1it,S Overheadtiters
w Serwice Amps VoltsOverhead ,dgrd No.of Meters
Number of Feeders and Ampacity
Location and attire of Proposedl t i r . i � Q
n
Coweletion oftheLollowingtable may, waived Ly the Inspector f Wires.
Luminaires
�E w.. .N . .. Total No. of Recessed
, W
.of Luminalrel of Tubs Generators KVA
Above In- emergency Lighting
. Luminaires swimminggrxid. ery 114-11
JI
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No,.,of Receptacle Outlets jo No. ;fi r �F CAMS lNo. Z n
itches „_ No. of i" and
I Initiating Devices
No. of Ranges N . C No. oj'L-Sw No.of Gas Bul rners I
Total
Tons No.,of'Alerting Devices
,� eat ..'. nwq.,IK.......! .off"SelfContained. e s tier Totals ............ Detection/Alerting
No.of Dishwashers A Heating o �al her
Heating fiances_ security Systems-,
No. of DryersKW` No.ofDevi"ces or Equivalent
. ate'Heaters KW . ' No.of
Ballasts Data Wiring:
Signs No.of Devices o iant
Telecommunications Wiring.
Hydromas'sagle Bathtubs No.of'Devi"ces or Equivalent
OTHER:
oe
Atiach additional detail d i required the Inspector of Wires.
Estim ated,Value of Electrdcal'�Yqrk-: (When required by municipal poli
Work to Stem: N fnspections to b r,requ,ested accordance with WC Rule � upon l t'
INSURANCE : Unless waived by the owner,in. mit for the perfonnance of electrical work may issuo unless
the IiGensee provides proof of liability insurance f f "completed oper ion"coverage or its substantial equivalent. Tie
nn rs'9 ned cortifies that,such force, n h ite proof same t the,permit in office.,
CHECK . .S ,,- N ErBO R D (Specify:)
jfy� un der th e p a M* s an dp en alfi j erjuq,teat th e inform ation on th is,applica l is true and cont
NAME: .
0-00
;.
Address-(Ifappli'cable,enter "exemVt 7 license number line), Bus.Tel.No.:
hL Alt
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Ver M.G.M.G.L c. 147,s.57-6 1,securlity work requires Depailment offublic Safety"S"License.- Lic.No.
INSURANCEA E : f am aware that the Licensee does not have the liability insurance coverage normally
r uix law. * ature below I hereby w .i e this requirement. the one)[]'owner agent.
Winer/ gent i
RM
Signatu �eNo.
012 Massachusetts Electrical Code Amendments 7 NM 12.00 Rule : In accordance-with the provisions of M. .L: . �� , L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.Ater a permit application has been accepted by an Inspector of Wires appointed pursuant uant to M.G.L c. 166, § 32, as
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of comp ledon of the work as required in M.G.L.c.143,§3L.
Pennits shall be limited as to the time of ongoing construction activity,acid may be deemed by the Inspector of Wires abandon d and inval€d if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,are extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either-the owner or the installing entity stated on the permit application.
'T`he Per mit Extenslon Act was created by S ection1 73 of h.apter 240 oftli e Acts of2 10 and extended by Sections 74 and 7 5 of Chapter 2 3 8 of
the Acts of 2011 The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that Nara
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending-through August 15,2012.
❑ Rule 8---Permit/Date Closed. Note:Reapply for new permit 0
❑ Permit Extension Act—Permit/Date Closed:
iTrench Inspection
TM
Pass M. Failed W Inspection Required El
InspectorsComments:
Inspectors Signature; Date:
SERVICE INSPECTION:
Pass Failed ? T Inspection Required D
InspectorsComments:
InspectorsSignature: Date:
PARTIAL ROUGH INSPECTION:
Pass V1 Faill d ? R Inspection Required El
Inspectors Comments:
Inspectors Signatur : Date:
ROUGH INSPECTION:
Pass Failed Re-Inspection Required} El
Inspectors Comments:
Inspectors Signature. Date;
FINAL INSPECTION:
Pass ? . "~` Failed Q Re-Inspection Required 0
Inspectors Comments:
Inspectors Signature. Date. 0/
DEB WEI NHOLD ...TOWN OF 11ME RIMA ,MA. .......c weinhold@to nofinerrimac.com
The Commonwealth ofMa a chusetts
. Department ofIndustrialAccidents
Congress Street Suite 100
Boston,MA 02 -2 . 7 t
'�, ww w.mass.go dia
Workers'Compensation Insurance Affidavit; udders Contractors) I ctri*cxans lumbers.
TOFF FILL]WITH TUE PETTING AUTHORITY.
A cant Information Please Print Leaibly
Name s ss rani tl'on/ndx idtxal): 47�i�4
Address: } �i
SttZ �f � � ou Phone #:
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Are you an employer?C h e ck the appropriate box: Type of project required):
1.[]I am a employerwith. - __employees(mil and/or part-time).* 7. Ej New construction
2,��am a sole proprietor or partnership and have no employees workiag for x e in 8. Remodeling
any capacity,(No workers'comp.insurance required.]
. 1 am a homeowner doing all work myself.[No workers comp.irisuranc arequied.�
s . Demolition❑
10 El Building addition
4. 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 1 I.[]Electrical repairs or additions
proprietors t no employees. 12. Plumbing repairs or a,ddi io .s
5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet.
13. Roof repairs
These sib--contrractors have employees and have workers comp. .surancc_
{ t of'exemption per MOL c. ��.�Other
.[J we are a corporation and its fflcers have exercised their light p
12,§1 4,and we have no,epployegs. o workers'comp.insurance required.]
Any applicant that checks box##1 must also fill out the section below showing;their workers'compensation policy it `ormatiorL
I-lom who subnn phis af da-vit indicating they are doing all work and they,hire outside contractors nest s4brnrt a xzcw affidavit indicating such.
)Contractors that check this box must;attached are additional sheet showing the name of'the sub-contractors and state whether or not those entities have
employees. If the sub-o ntraotars have employees,They must provide their a rkeis'comp.policy number.
I am an employer th at isproviding workers-)compensation insurancefor my einp ees.'Below is thepolicy andiob site
information.
Insurance Company Name:
Policy##or Self ins.Lie. Expiration ate:
0"",tl, 17Lt
Job Site Address. bb t p
Attach a copy of the workers' compensation policy declaration pages owing the policy number and expiration date).
Failure to secure coverage as required under M L c. 152,§25A is a.criminal violation punishable by a fine up to$1,500.00
and/or one-gear imprisonment as well as civil penalties in the forn of a STOP WORK ORDER and a fine 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
coverage verification.
o hereby certify ender tie ,
Date:
s nd nal i .f er n that the information�rro ided above is true any correct.
........................
i ate:
Phone #: `
Officialuse only. D not-write an this area,to be completed by city oi-town o;ff ficial.
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
ContactPerson: 'hone#:
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This certifies,that /
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