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Commonwealth of Massachusetts � "
c.>tLrer wl 1�se r�,rl
Permit No.
u. Department of Fire Services
Occupancy and ire Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07]
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perforate,c1 in accor(Jance with the flusaswclacrs tt 1'lu 'traa el r.O&(ttr C.) 527(WR'12,00 l
(PLP,> S'E'P?Iti INI IN INK OR TYPE ALL INk OR.h A ION) Date, 6
City or'rown ot: NOR rH AN'I)O E1 7i)the Inq)ectol,q ff Tres.
By this application the undersigned gives notice of"his or her intention to trcrforua the electrical work described below.
Location(Street c Nquuiber) r tr Al,
Owner or"tenants A'� ,. I"elelplpone Ntp "" ` a. at,c
Owner's Address10
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Is this permit in conjunction with a building permit? Yes � No ('
permit J permit?'r � L_..i ( :`heck Appropriate Box) (�
Purpose of Building _ _ utility Authorization No.
Existing Service Amps I"I i"0 Volts Overhead, Undgr(l No.of Meters _4— r
New Service Amps / Volts Overhead Undgrd El No.of Meters t
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Number of Feeders and Am pacity
Location and Nature or Proposed Electrical Work:
� vd; .re
Completion rletion o the Grlhaa,in,sal I �a,ere smairred 1)x the Irns.xctor o N''ir es
No.of Recessed Luminaires p,(Paddle) o. otaNrr.raf l';ere Sras I'.prlrlle I+'rips I"rarmer, K VA C t l
No.ofL.;uminaire Outlets Noa of HotTonsGenerators KVA C
._._ A ove ap- ap.o t�tnea°gencyLighting
No.of Luminaires Swimming Pool rrrI � p•ncL. El Batter units
No.of Receptacle Outlets �- No.of Oil Burners FIRE ALARMS No,of'zones
ra.0 7eteetron an- m....
No.of Switches � No.of Gas Burners I"or Inptaatm p Dt vices y
No.rat Ran res No.rri"Air C arnrl. Na of Alerting hlevices
Llrvices ! r
No.of Waste Disposers �at ramlp uanlper cans o o e ont°tpne
I I'"wptaNs. .. . . DcteetatrnJAhrl �
�"� Mrrwprr pearl
No.of DishwashersSppcc/Ap ea LLeatwng KW L pral❑ C rannrctau11 ❑ Other
_..______."�`er.0 tyyste•waps:�®, ,..
No.of Dryers LL�eatippg Alplpli'arares 1£:W
No.at�e,viccs rri F.c tpivaleppt
o.rp ater o.KW 0 � er.o Data Wiring
Heaters Si*ns Ballasts No of Dcvtces or Er uivalent
I e ecom munacatwons urwng:
No.Ilydromassage Bathtubs No.of Motors Total LITr No of I)evaces or Ertrpiv:rleart
OTHER: l
rf1fach addilional detail a cicsir ed or as required G.} the Inspector of 0lires.
i
Estimated Value of Electrical Work: _ (Wben required by municipal policy,)
Work to Start•. C, Inspections to be regiwestcd in accordance with MEC"Pule 1.0,and Moon completion.
INSURANCE COVERAGE:E: Unless waived by the owner,no pennit Liar the performance of electrical work may issue unless
the licensee provides prepof of liability insurance including"completed operation"coverage or its substantial equivalent. The t
undersigned certifies that such coverage is in force and has exhibited proof of same to the permit issuing office. 1
CHECK ONE: INSURANCE Eg BOND ❑ OTHER ll:;R [] (Specify:)
I certd" under the Amine maul enattir o er"u} pc information errs this application is true and complete.
' .1Y� I p, J'p Ira,that td
FIRM NAME: " ,�. ,� . .. � tr t a e ILIC.NO.: /C�
�___.
csee: 5nla itc e,1er nsrtw e� ad �&Z—
(1j'applicab1c, LIC.NO.:eMer e g y n raurarGcr line.) 2E
Address `. ,� ) �� t 1.No.:4
*Per M Ca L c.147,s.57 61,security work.requires I)epartruelit erfPublac S"aioty S License:nse: Luc No
OWNER'S INSURANCE WAIVER: 1 pup.aware,that Iare Licensee does prat have the liability inntarancc,coverage;normally
required by law. I`.iy iffy signature below,!hel,elty waive this requirement„, I ant the(chccak erne _.. ownneer�� owneL' agent.
Owner/Agent. PF.�HIT T'E E $ � ..�
Signature "telephone No. �_ f
P
..............,,�.
A�'
The Commonwealth of MtrssttcXtuseatts
Depar°g ent of. nd .strialAcc:zdents
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1 C"crra r'cAs' ,S"fir° et,Suite00
Boston, UA 0211 '-20.17
www inass,govlcfta
Uorkers'UComb>enrsationinsuranceAft►davit Ilttildeits/C"orntractors,/if'lectrrc°isns/Illu7ml)ers.
1,0 BE,klLp!:L1 W1'1'11'➢),1K'PE RM'I'I"FIP'G AVI'1710RrrY.
Applicant Infaranatioar Please Prirrt I:�e ih1 �%
p/
Rattle(Business/Organr'zstion/Individuat _.: _.,._ ............._.
a � sAddress: ..City/State/zip: f �_..._,�. _ .-_.. �
_..... ...,._._ _ _..w_ ._..__-_._. .._ _.___.____ _ j,
Are you air emplayer7 Check the appropriate host Type of project(required):
1. I am a employer with ...___. ...,,.._employees(full and/as part-time).* 7, ]New construction
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2. 1 saris a sole pruprietoror partnership and brave nca errrptoyoca S Working;frJr me fit s, Remodeling
any capacity.[No workers°comp.insurances recluirect.;] q Demolitionl
3.�I am a homeowner doing all wordy myself
[No workers'camp.in as aarue required.]t
lE) Btri}drnpt addition
4.[:]I am a homeowner and will be hiring contractaa s to conduct all work'on my property. I will
COMM that all contractors either have Avcukers'campensation insurance or are stile It, Electrical repairs or additions i
f;
proprietors with no employees. 12,E]Plumbing repairs or additions
5.L]I am a general contractor and I have hired the srab-contractora listed on the attached sheet. 13.EJ Roof repairs
These subcontractors have employees and have workers comp insura n(e,.l
6.❑We are a corporation and its officers have exercised their a¢g)rt of exemption per Mal.c.
152,§1(4),and we have no employees.[No workers cornp insurance requited] __ _..._ ...
*Any applicant that checks box#t must also fill out the section below showing their workers eornpe nsatton policy irtfonnatlon,
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContactars that checkthis box must attached an additional shoat showing the name of the sub-contractors and state whother or trot those entities have
employees, If the sab-contractors have employees,they must provide their workers comp.policy number. mm W
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f nor an employer that is providing dvo*er.v'crrrrnpen secton ansuranew./or rap employees. Below is the pollcy anti job site l
infor inatlon.
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Insurance Company Name: ...__ _....___..._....._......._ _....._
Expiration ........� �
Policy#or sell'-ins.'Lic,.fl..__._ _..._.._.__ ... ____ ._..__._-_._.._..,-_ _
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Sob Site Addrt ss: _ __ _ __..,City/State/Zip:._. ....____,_._......_
Attach a copy of the workers'-corupensation policy declaration page(showing the policy number and expiration elate). r
Failure to secure coverage as required under MGT c;,1.52 §15A,isa criminal violation punishable by a.ffnc rip to$1,500.00
as well as civil penadt�ies ill file�forin of a s'rO.P WORKOR:C)'F,�R and a-fine of up to$250.00 a
and/or one-year imprisonment,
day against the violator.A copy of this statement may be forwarded to the office of Investigations of the DIA'f"cal°insurance
L
coverage verification. _ _ -.--.-----..----
Z cla hereby c�erftf' rarac(e the pa'r¢ cal praties°t?f"lrer�acry fleet rice lrtfor°rnrttlrrn lrr°ovr'eCerC above Is tune and correct.
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Official use only. DO rent It' to in this area,to lie a:.rrrrrlaletecl/iy city err town official
City or"f'own; Perrrrit/License
Issuing Authority(circle one): &
1.hoard of health 2.I3uifding Department I.("ityll"own Clerk 4.Electrical Inspector 5.PluntlAng Inspector
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therkact:l'ersans _ l honett: ,,W.___.__...
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