HomeMy WebLinkAboutWiring Permit - Permits #12504-1 - 50 COTUIT STREET 2/20/2015 w Date... ......................
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Cominonwea&ol MaMachuJeffi Official Use Only
Permit No. 1Ix
2epaptmed o `ire Services
Occupancy and Fee Checked
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BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
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APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W
All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00
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(PLEASE PRINT IN INK OR TYPE ALL INFOR14 TION) Date:
City or Town of: w ill
4 do d(r To the Inspector of Wires:o r A
By this application the undersigne gives notoe oe I
ice of his or her intention to perform the electrical work described below.
Location Street&Number
Owner or Tenant Telephone No.
Owner's Address 7e,,6 ei6
Is this permit in conjunction with a building permit? Yes El No ❑ (Check Appropriate Box)
Purpose of BuildingPP5)d ent e. Utility Authorization No.
Existing Service Amps 1 Volts Overhead Ej Undgrd❑ No.of Meters
New Service Amps 1 Volts Overhead Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: y
Com letion 2f the Lollo1vin table inay be iva hied by the Ins ector o Wires. �
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No.of Recessed Luminaires No.of Geil.-�Susp.(Paddle)Fans T • Total
ansfo�•men s I{VA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires SwimmingPool Above Ei In- 1:1 o.o Emergency Lighting
rnd. r nd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches o.o Gas Burney No.of Detection and
Initiating Devices
Total
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of waste Disposers Heat Pump Number., Tons IOW No.of Self-Contained
......................... ...............................................
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating IOW Local❑ Mun'c'pal El Other
Connection
No.of Dryers Heating Appliances KW Security Systems:
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters signs Ballasts No.of Devices or E uivalent
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 fflires.
Estimated Value of Electrical Work: 0 (When required by municipal policy.}
Work to Start: vim J9 inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVE GE: 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 BOND ❑ OTHER ❑ (Specify:) 6reql�i>
I certify,under thepains and Penalties ofperjury,tlrat the information on f1iis application is true anJ complete,
FIRM NAME; Q N�t LIC.NO.: 1Z_
Licensee: Signature ONLIC.NO.:
(If applicable, ente " xenzpt"in the license nrnnber*line.) Bus.Tel.No.: a`7 AEC 2
Address: '��t r? 04- Alt.Tel.No.: 4100,(1 V 1� -_
*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 haiie the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner El owner's gent.
Owner/Agent PERMIT FEE $ 079
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Signature Tele hone No.
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The Commonwealth of Massach usetts
Department of Industrial Aecidents
Office of Investigations
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600 Washington Street
Boston, MA 02111
jvww.mass.gov/dia •
• wit: �uilderslContractors�lectricianslPlumbers
Workers, Compensation Insurance Affidavit: .
p Please Print Ile ibl
Applicant Information ..
Name (Business/organizationlIndividua).
Le e) "7 0,
Address:
�f
�I k"Al Phone#.
e:� 7
City/State/Zip.
_—Mak the a ro riate box: 7J
Type of project(required):
Are you an employer. Check pp p
• 4. El I am a general contractor and I 6. F1 New construction
l.[1 I am a employer with sub-contractors
es (full and/or art-time).* have hired the s 7, Remodeling
employe p z
proprietor or partner- listed on the attached sheet.
2. I am a sale propz p Demolition
ship and have no employees
These sub-contractors have 8.
working for me in any capacity. workers' comp. insurance. 9. [1 Building addition
p �.
' . insurance 5. E] we are a corporation and its 10. Electrical repairs or additions
�o workers camp officers have exercised their
required. ion per MIL 11.C]Plumbing repairs or additions
a homeowner doing all work right of exempt p
3.[� I am and we have no Roof repairs'
a c. 152, �1�4},a 12:[]
myself. [No workers' comp. workers're wired. fi employees. [No13.[I other
insurance q .
camp. insurance required.]
1 out the section below showing their workers'compensation policy inorxation, _
*Any applicant that checks box#f must also.fil a'
' . icatin :the.fare-.doing all work and;then hire'oufi.�ide contractors actors must submit a nevv affidavit indicating such.
Homeowners who submit this aff davit_Indic g Y _. _..
C.ont actors-that check this box must-att
ached an additional sheet showing the name of the subcontractors and their workers'comp.policy anfol�naton.
. � insurancefor nz em lvyees. Berojs�is t►iie policy and,�o�sr"te
m an employer that is providing)vorkers compensation t y p
Ia
in forinationo
Insurance Company Name:
• #: Expiration Date:
Policy#or Self ins. Lie.
Job Site Address.
City/State/Zip:
' 'c declaration a e(showing the policy number and expiration date).
Attach a copy of the workers compensation policy p g
' L c. 152 can lead to the imposition of criminal penalties of a
Failure to secure coverage as required under Section 25A of Mo d a fine
• risonment as well.as civil penalties in the form of a STOP WORK ORDER an
fine up to$1,500.00 and/or one-year imp s to 250.00 a day nt may be forwarded to the Office of
of up $ y against the violator. Be advised that a copy of this statement y
Investigations of the DIA for insurance coverage verification.
• and penalties o er"rtry that the information provided above is true and correct.
I rlv hereby certify under the pains a p !f .l
Date.
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Phone#.
• ea th a cant �eted by city or tolvit 6_fftciar�
Official use,only. D not write in tliors ar p
City or Town.
Permit/License#
Issuing Authority(circle one);
. City/Town
/'I`own Clerk 4.Electrical Inspector 5.Plumbing Inspector
1.Board of Health 2.Building Department 3. ty
6,other
Phone#
Cont
act Person: '
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