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Home My WebLink AboutWire Permit - Permits #12987 - 366 CANDLESTICK ROAD 12/15/2014 R �\ 1 OEM ON Date....,. M III �\ _ NI \\ IMIN NDO \\ QTN NORT is :� t,. ► E \� I MO \� MEMO V t} S` \\ 'x SEEK KIM M Usti ' _. Mi MO ggp \� q. . AdMMoM INl=l v W This certifies that ......... -el ............... _.. N erfc has tssn t� ......... .... ...... .......... ..........„ building �f . .. ..... W\ wiring in e __,_ WIN 4 N h ndever, assMIN -0111 \\ ri ISM iSPECTOR g qa 'ICr1L €` � IN Fee....... ..< �\ "I o- IMM check ININE ' LI �� (f.nwea&al Va-mac4aiefli Cifficial Use Only Permit No. z Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEA,3E PRINT IN IN OR TYPE AL '70RMA T ON) Date: J�7 ".. 21-/// City or Town of. A)6LV A ( r" To the Inspector of Wires: By this application the undersigned gives notice of his or her intrition to perform the electrical work described below. 36, A Location(Street&Number) S Owner or Tenant - /7 Z r/ Telephone No. Ci Owner's Address A4 f2l Is this permit in conjunction with a building permit? Yes F] No 0 (Check Appropriate Box) Purpose of Building_ e 1 del', Utility Authorization No. 'Existing Service Amps Volts Overhead Undgrd ❑ No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1A) i r e (3" et `,) 2-1a lu-iv4�,CL Completion of the followingtable may be waived by the Inspector ol Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above [:] n r- - -No-.of Emergency Lighting [3 grnd. g ad. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS JNo,of Zones No.of Switches 4 o.of Gas Burners No.of Detection and ---)/TOM— Initiating Devices --- No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump I Numberjxons-- I.NW No.of Self-Contained Totals: ..........* Detection/Alerting Devices n Municipal No.of Dishwashers Space/Area Heating KW Local Connection [I Other 'ge—eurity S stems:* 00 No.of Dryers Heating Appliances KW No.of stems: or Equivalent No.of Water No.of of KW Ballasts Data Wiring: Heaters Signs 1, - Non of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Felecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electri l Vdork.- (When required by municipal policy.) Work to Start: 1 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE,COVE AGE: 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 F1 (Specify:) t-,4",C,, I certify,under the pains and penalties of penury,that ;# the inforMation on this application Lv true and complete. FIRM NAME: LIC.NO.: 3M�"17 Licensee: Signature LIC.NO.: V, (1j'applicable,enter exempt"in the license number ine,), , "',I � - Bus.Tel.No.: Address: r1,v 41'7 e4 e, c k, e Alt.Tel-No.. *Per M.G.L.c. 147,s.57-6 1,security work requires Department of Public Safety"S"License: Lic.No. 7 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)[]owner []owner's,4gent. Owner/Agent Signature Telephone No. PERMIT FEE. $ 12A t 155U1jj11 E EGOr �R� GI Fp( \Ji� tF a1. 4 1 irD 4_ The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Address: 54rpe City/State/Zip:_ M 04hone#: el Are you an employer? Check the appropriate box: Type of project(required): 1.F-1 I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction *employees (full and/or part-time).* have hired the sub-contractors 2. 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' comp. insurance comp. insurance.: required.] 5. We are a corporation and its I O.n Electrical repairs or additions 3.F1 I am a homeowner doing all work officers have exercised their I I.E] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.n Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13T] Other comp. insurance required.] I I *Any applicant that checks box 41 must also fifl out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing A 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 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 r the painsand enalties ofperjury that the information provided above is true and correct. 4ture:Sip Ile 77 Dane: Z,,�2, . 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 Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: