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Home My WebLink Aboutwiring permit - Building Permit - 725 BOXFORD STREET 9/16/2014 Date M ' ......... �..... �,►�•`' ��: :�. oM T,®�/I\I O \J L F FORTH q p� p } F'E'RMIT FOR WIRING �BgCHUBE� This certifies that e . has permission to perform " , _( at Wlring In the building of f . a g°_ �i at �y Fee >N rth A ver,Mass. ndo..... ......Lic. No .............. f ry ............ .. - J F Check# � Ec cTTtrc [ IrvsPEcrox Clounonweafilt of Ma,4jac1zu,4effJ Official [Jse Only 2aparfinent of,..`ire Septlicei Permit No. BOARD OF FIRE PREVENTION REGULATIONS [ROccupancy and Fee Checked ev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC 5277R 12.00 (PLEAS SE PRINT IN INK OR TYPE, AL ,INFORM. TION) Date:_ / 7 City or Town of: kvr� To the Ins�eclor of Wires: By this application the undersigned gives notice dhis or he�intention to perform the electrical work described below. ry Location(Street&Number) 1/1-1 ha Owner or Tenant - ),L ell It e?pltq 6,t je'i Sit" ej Telephone No. Owner's Address A A /I Is this Permit in conjunction with a building permit? Yes El No F] (Check Appropriate Box) Purpose of Building J, ilk -e Utility Authorization No. V Existing Service Amps Volts OverheadF] Undgrd ❑ No.of Meters New Service Amps Volts Overhead F1 Undgrd ❑ No.of Meters Number of Feeders and Ampacity ct Location and Nature of Proposed Electrical Work: �\ a i JI 6 Coniplelion of thefiollowing table inay be waived by file Inspector of Mires. No.of Recessed Luminaires No.of Ceill.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KYA No. of Luminaires Swimming Pool Above In- No—.of Emergency E-ig"Fifi—ng grnd. ❑ rnd.g Battery Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches No ofGas Burners No.of Detection and'D Initiating Devices No. of Ranges No.of Air Cond. lotal No.of Alerting Devices Heat Pump Tons No. of Waste Disposers J.K-W No.of Self-Contained Totals: Detection/Alerting Devices i. No. of Dishwashers Space/Area Heating 1{W Local n Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water No.of No.Of No.of Devices or Equivalent KW Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total UP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of[Fires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start, (J�', I I\ 9 Inspections to be requested in accordance with MEC Rule 10,and upon completion. j, 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. CHEfy'ONE: INSURANCE BOND F] OTHER F] (Specify:) I under the Carus andfienalties ofpeijury,that the information on this application is true and contlVele. FIRM NAME: L � / , /,- LIC. NO.: Licensee: Signature LIC.NO.: (tfaAddress:pplicable,enter "exenipt"in the license nuinber line.) VV Bus.Tel.No.: I � , ,_ �"� ❑ Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.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 below,I hereby waive this requirement. I am the(check one 1:1 owner 1:1 owner's agent. Owner/Agent q-11 Signature Telephone No. PERMIT FEE: $6 D The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations ° =- 1 Congress Street, Suite 100 Boston, MA 02114-2017 . .� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): i 1 e" Address: I, " City/State/Zip: & '„ . r 01) 9' Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. F1 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 1/0 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' camp. insurance comp. insurance.t required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I Ln Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other 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. IContraetors 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un er t re pains an penalties of perjury that the information provided above is true and correct A � Si nature: ,,......._ , ". Date: r Phone 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 Cleric 4. Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: 4v�OMNfQN1.1�� : i:SSUES .THE fOLLOWiHD `LFCENSE a , . 34URNEYMAN ELE CTR i C.t AN i LEONARD SR DEXTER $� 1844 5�±t 9 a hlETHUEN A 64441