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Clmlnonwea& Permit No.
2,�oartnwnt o/J!,-, Services Occupancy and Fee Checked.
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[Rev. 1/071 (leave blank)
BOARD OF FIRE PREVENTION REGULATIONS
APPLI("#'ATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(M ) ?27 12.
(PLEASE PRV�TIN INK ORTYP ALL INFORMATlolv) Date: f
Tres:
S.
�b the Inspect o res:i
I"""I work
City or Town of: described
By this application the undersigned gives notice f his or her intention to form the electrical work described below.
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Location(Street&N!��, P.r
4
Owner or Tenant Telephone N C. 5,tV �
Owner's Address Yes 0 No (Check Appropriate Box)
Is this permit in conjunct' with a building permit? [X\
Purpose of Buflding����� Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Und-rd❑ No.of Meters
New Service Amps f Volts Overhead❑ Und-rdF-] No.ofM,ters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical. Z
ColljEletiol,of the IbIlowin table may be 1ti-aivedbv the Ins2ector ol'Wires.
No.of Total
No.of Recessed Luminaires No.of Ceil.-Susp-(Paddle)Fans Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs
Generators KVA
Above In-
0.0 mergency ic ting
No.of Luminaires ❑ pared. ❑ Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS �No.of Zones
No.of --ection and
No.of Switches No. of Gas Burners o.tal Initiating Devices
I
Na.of Air Cond. No.of Alerting Devices
No.of Ranges Tons n
cat Pump Number Tons KW Na. ined
No.of Waste Disposers Totals: netection/Alerting Devices
Na.of Dishwashers Space/Area Heating K =❑ Connection
KW Local" MuniciMunicipal [-� Other
Appliances KNV Security Systems:*
No.of DryersNo.of fl—jr- or F uivalent
No. of No.of Data Wiring:
No.of Water KW Ballasts uivalent
Beaters lt No.of Devices or E
ejecommunications irina:
No. Hydromassage Bathtubs No.of Motors Total HP No.of Devices or EquivAent
OTHER:
Attach additional detail if desired, or'as required by the.Inspector
(When required by municipal policy.)
Estimated Value of Electrical.Work-: accordance with MEC Rule 10,and upon completion., 3
Work to Start, Inspections to be requested in ance of electrical work may issue unless
INSURANCE COVERAGE: Unless waived by the owner,no pen-nit for the per-form
,*completed operation 11 coverage or its substantial equivalent. The
the licensee provides proof of liability insurance including
0 1
undersigned certifies that such cover;.ge is in force,and has exhibited proof of same to the permit issuing office,
CHECK ONE: INSURANCE �BOND 7 OTHER [I (Specify:) Z�
I certify, under the pail's and penalties of perjury,that the information on this application is true and complete.
LIC.NO.:A I L9_1
FIRM NAME: r)c:zd'
Licensee: Signature LIC.NO.-
-1134;
(If applicab el.No. a
Address: -3-7 V"12 Al't..'Tel.No.. �-11
Public afety"S"License: Lic,No. �5ii�S--
*Per M.G. s not have the liability insurance coverage normally
OWNER' 0
required by law, By my signature below, I hereby waive this requirement. I am the(check one) 11 owner F owner's acent.
Owner/Agent PERMIT FEE: S
Signature Telephone No.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
www.inass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Con tractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individtial): SPEED WIRE INC
Address: 1750 N FLORIDA MANGO RD SUITE #106
City/Sjane 561 254-8610
te/Zip:WEST PALM BEACH Pho
Are you an employer? Check the appropriate box: Type of project(required):
1.AM I am a employer with 10 4. 1 am a general contractor and 1 6. F1 New construction
employees (full and/or part-time)." have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. Fj Remodeling
ship and have no employees These sub-contractors have 8. El Demolition
working for me in any capacity. employees and have workers' 9. E] Building addition
[No workers' comp. insurance comp. insurance,T
required.] 5. f-1 We are a corporation and its 10.7 Electrical repairs or additions
officers have exercised their 11.7 Plumbing repairs or additions
El I am a homeowner doing all work right of exemption per MGL
myself. [No workers' comp. c. 152, §1(4), and we have no 112.7 Roof repairs
insurance required.] t employees, [No workers' 13.1 Other BURGLAR ALARM
comp. insurance required.] i
*Any applicant that checks box#[ must also fill I out the section below showing their workers*compensation policy in rormation.
f I liomcowicri Nvho submit this affidavit indicating they are doing all work-and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the stab-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
Iam an employer that is providing workers'compensation insurance far nor emplkrees. Below is the policy andjob site
information.
Insurance Company Name-.LOCKTON COMPANIES LLC
Policy# or Self ins. Lic. #:C4793820A Expiration Date: 10-01-2014
Job Site Address: ALL LOCATIONS 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 the paints and penalties ofperjtirylliat the iiifonitatit)iiprotideti afro e s truet tdcorrect.
Signature: Date:
Ph ne#:
Official tise only. Do not write in this area,to be completed by cio,or town official.
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
Contact Person: Phone#:
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License' SS-001895
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r CHMSTOPHERJ TREMLAY
393 Jericho Tpk:S6
Mineola NY 11501
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