HomeMy WebLinkAboutWire Permit - Permits #12879-1 - 120 CANDLESTICK ROAD 11/23/2015 W
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Official Use Only-
7-�PermitNo.
Occupancy and Fee Checked
BOARD OF FIRE PREVEII-11011 REGULA71 IONS peli.liq (leave blank)
F07--Z P�'ERRIOLIT T' o ELECTLRUQAkL
Allurork to be performed in accordance%vith the Massachusetts Electrical Code 6VIEC),527 CMR 12.00
(PL F.,1 SE PRflVT D,T-ri Vj,.-OR YT-PE,ALL Np-01U,121F,0119 !)tts. I'R 0 t
(Citt"'r
Sy this applicaffon the und o7-qjF Wb-es.
Location(Streel.&-Num." Lion to perform e xt work described below.
01vner W- Tan"Int
13wner"s Address
vs this perrait in c (Chaek AD rop lap te%,. x)
Purpose Or Bull", rLzaldor.No. I P
Existing Service
AmPs 12-t)I Ovorhacd -Jnd'g,-�d
D' Undgrd 0.1,FWe"ers
lqu-'aher Of Feeders and iiannacity
Location and jqature of proposed glectrca,
1 4�51111re'i
TIC.tea'Recessed Larninnires 740.of tcel--Susp- addler)Fans Total
No.of LUMI-nalre ou-dets Dfo'C27 Hot Tubs Tra aormers KY (Z
Generators 210!A
Ple.UfF L'Gmirmtes I —
Noaof?Receptacle;cutlets
of Zones
f:Kaages
Na.el Air otaT.
�Pqo.Of Alert!ng Dewices
a
Devices
No.of Dishwashers .............
Other
Wo.of Dryers
Y
o4o.OF Date,W iring:
of'Devices or.-z un"alent
No drom Ing
No.ofrtllotors Total 1,
OT M-5 E R:
Estimated V f E Value or Sao (11,%ea :r !:lieq;; iiulirle!��di:lb!!�yl�i�!!:Im'!Il�unic7ipalpolic�,�)
I llb )0xrequh-zdkj: !1!'?e 11"SPedor of 1111rox.
'Work to start:L inspections to be requested in accordance'alith MEC Rule 10,and upon completion.
ia-la/—) '
INSU RA"INCZ COITR RAMI: Unless waived by the ovner,no Perin it for the performance Of electrical work mar issue u n I ess
th
e licensee provides proof of liability insurance including"co pi ted operation"cove e or its substantial equivalent. The
Or=,and has tWilibited pr;orof same to the pernift issuing oF�jce.
undersigned certifies that such coverage is in r m erag
CHECK.ONE; INSURANCE X BOND OTHER [] (Spocil
f certojp,ander ffzepahjw mid p-analife
le'
F 0fPe?*TY'tflat"le 14forraaff0y'Or,illis OPP11cafi0j,is 1'rue and co;7vjeta
Licensee:. /rl�
'U-&7PPjkabja,e7f,1-
3 Ts.Tel. 4� 7 70
L
eel',
L.c. 147,S.57-61,s Ah- ii-a-ric.-
'Per PM.h. entof Public Safbty"S"License.
Lic.No.
aWNEW's!NSURJUNCE I v.U, an-INMe that t3se L censee does izot 1mve the liability insurance coverage normally
,equired by law. By my signature below,I hereby Waive this requirement. I am the(check one no
jwner/.Agent - I owner M owner,
signature
Telephone No.
The Commonwealth of Massackusetts Print Form
± - Department of Ind zap"Accidents
Office of Investigations
r _ I Congress Street, uite 100
Boston,AM 021 4-2017
www.mass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
li ant Information I lease Print Ise ibl
Name (Business/Organization/Individual): j,� "' i ' e c r. 1 w._.. ` �' 1 j e r",. '/9 '
J
Address: / ' L `=j ../
City/Mate/Zip: 100(F � Cif Pl a' Phone# ;>. ar
Are you an employer?Check the appropriate box: Type of project(required}.
1.9 I am a employer with �' 4• ❑ I am a general contractor and.I
employees(full and/or part-tune).* have hired the sub-contractors New construction
2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling
shipand have no employees These subcontractors have
8. F1 Demolition
working for me in any capacity. employees and have workers'
insurance.« (�wilding addition
corn
[No workers'comp. insurance p•
required.] 5. [] We are a corporation and its 10.ErElectrical repairs or additions
3.Q I am a homeowner doing all work officers have exercised their I1,El Plumbing repairs or additions
thyself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]1 c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comn.insurance required.]
*Any applicant that checks box 41 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.
*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 moistt provide their workers'comp,pokey number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy anal job site
information.
Insurance Company Name: 77 1 a`
Policy#or Self-ins.Lic.#a L try [ � Expiration mate:
Job Site Address: Cd . City/State/Zt
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 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 ILIA for insurance coverage verification.
I do hereby certify under the a, s and penalties of perjurer that the information provided above/as true and correct.
Phone#: r../ ._ i'Ja `;"
Clfffcial 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 5.Plumbing Inspector
.Other
Contact Person: Phone :
,A A
�LE.CTR1 C{{�RdS
{ UE5 THE ,FOLLO��NG Lt'CEt�SE AS
EOi S"C' REq MASTED.
KEG t14
..R EMMETT .
PO. Bo 794
I,�.C?CtL I GIP! kA O t g49 2794
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15719k 6 50778
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a COMMONWEALTH F S 0HUSF.TT
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ELECT `IC1A 5
ISSUES„ SHE FOLLOiR L10EN"E "
AS A FtG JOURNEYMAN ELECTRICIAN'
KEW I PI R EMMETT ..
m . 794 .. ,
A .DDLETON MA O1949-2794
37432.E.
07l3t/t 50777 . .
l"EjLwmzluww t
STATE OF NEW HAMPSHIRE
BUREAU OF ELECTR CAL SAFETY&UCENSING
NAME-KEVIN R EMMETT
1. 10258 M
2.
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EXPIRES: 09/3012 1