HomeMy WebLinkAboutWire Permit - Permits #12627 - 52 ESSEX STREET 8/21/2014 �`
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130ARD OF FIRE PREVENTION REGULATIONS Rev.1//07cy and Fee Checked
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APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Cate(MEC),527 CMR 12.00
� ALL 1 F`OR TION) Date:
the Is ectar o.
(PLEASE, PRINT!N IXK OR TYPE i
City or Town of: p f Wires:
By this application the undersigned giv�otic or her intention to perform the electrical work described below,
Location(Street&Number)
Owner or Tenant " m i Telephone No,
Owner's Address
Is this permit in conjunction with a building permit" Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd t__.i No,of Meters
New`service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of feeders and Ampacity
Location and Nature of Proposed Electrical Work: . )
Ca letion of the ollowin !able maybe waived b the Inspector o Wires.
No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans a,of otal
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Na. of Luminaires Above n- 4.o mergency g g
Swimming Pool %rod, grud. Butte Units
No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of pines
No.of Switches No.of Gas Burners o.or Vetec ou an
Initiating Devices �-
No. of Ranges Na.of Air Cond. Total Taal No.of Alerting Devices
No.of Waste Disposers eat ump urn ,r _,arts, . o,o e antaine
Totals: Deteedon/Alerudn Devices
No.of Dishwashers Space/Area Heating KW Local 0 un c paCannectian
D Other
No. of Dryers Heating Appliances KW 19—fturity S stems:
�T�7eim.a W-titer
No.of Devices or Equivalent
!!eaters KW 0.0 0.0 Data Wiring:
Signs Ballasts No.of Devices or Equivalent
lr._.�...._ �Bath�tubsa ecammunicatians irin ;
No llydrornassa No.of Motors Total HP No.of Devices or Equivalent
nt
.Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work.` ""
(When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: 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 co ge is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
l certify, under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME_ i: LIC. NO.:
IAcens
. .
�afrl�me 4p Sign
(lfaPPl �;��' .^� ....._Bus.Tel No� '�
exem t"t h lice a number ine.)
Address: �� Alt.Tel.l, No.:
*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 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 agent,
Owuer/Agent
Signature Telephone No. PERMIT FEE: S �
The CommrtoniveaZth of.1 assaOusefft
• - Office o,f lnvesfigufeons
600 Waskington,Rest
Poston.,.tom 02111
-wip. uss govId a
WorcReo,compensation Dswance Affidavit:lInAdergfContractor6.EZect czans1?1* erg
A plzcax fra a xuatXaxa Please.Pri at ,edbly
a a[�usi�ess/fJzganizationlZnd%viduaZ: y %)3 nAl
y
Ara you�m employer?+Cb. A the appropriate hox: Type of project(ceq;rrixed),
1,El f am a amployar with_ _ 4 El x am a general contractor and 1 6. fJ Now consfractioll F
employes(fiill and/or part time),* have nod the sab-eontractoxs
2.� 1 am.a sole propxietar or partn.ex
listed on the attached,sheet. 7. Remo
slip and`ltavono•emplayees These snir-conixaetorahave 8. E]:Demolition
worlang for me in any capacity. -work ors, comp.insurance, 9. n Bu frog addition
( o wor exs'comp.insru:ance 5• a we axe a coxporalion and its 10�Blea�icalrepairs ox ac�dr•tions
recloixed•� officers have exercised.their°
3-EllamahoaneowSterdoingallwaxy lightof'exemptionperMOL 11,. or additions
xnyseE Lowpikesa'comp. 0.152,§1(4),and wehaveno 12 f Roofrepairs
insuranca;re led. employees.['o workers'
1311 Other
comp.insurancomgaired.]
x.A��aX7plicaritfhaccfrecksbo�#ImusEaiso�Il,outfheseetion.beiowshowingfbeirw'orkers'compeasatiaupolicyinfom�afiioia. .�
t iromeowners who submzf thk affidavit indzcatingfhay a're doing atT sorb and:ben hire outside contractors must submit a new RfHda7it in iicatrng such.
xConfraotors that cheAthis box must affached an,additional sheetshowingthename oft-he sub confracfors roticyinfonnaiion.
.�'az.�r�czne.�z��oy��t�ia�i�,pzaviri%�g-NaQ�'.�e��'cornpe�asationir�sr��r�E?cefox.�r�yeznployees .��1'otui�t�ia�tolicyar�ri,�a�a,�iie
irz�o�.tnafior2.
Insurance CompanyIame..
Policy#or�el:�-xns..�xc.#; Expit:at�on,�ate:,�
lob Site Addxes.s' Z jy/Stafel�ila:
Attach a copy O t to orS ers'com exisatiou a cy cleclaravosr page(sb.a-wingtlte policy ntz ber and expiration:date).
*Failure to s0rmta ooverage,as regtx-rxeduadex,Section25A ofMGf,0.152 can,lead to tha imposition of criminal Venaltzes of a
f o,up to$1,500.00 and/or one.-year ltnprisonm-ent,.as well as civilpenalties in the form.of STOP WORK K .OBDE and a�xne
of-ap to$250.00 a day against t$e V 0Iator. B0 advised that a copy oftbis statement may ho foxwardedto the Office a C-
fnvestigations of flee DfA for ii3suranm coverage`verification.
do Xiere ry cer fy z�r c er die iains r�cipenaltieg of ve �rx y i�iai brie ire a atior�pr avi ec above z e and eorrect,
S� Date:
JV
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Offa�eMI USC OAry. DoY109Vfife in AVS area,fo die colg1efed by city or<forvr2 o elfff
City or Town: ------f'armit/fszceztse
IssuingAu-thu ity(circle bne):
I.Board[ofSfealffi 2.BuildangDepartwent 3.Cityffown Clerk 4.Mectxicalfnapector 5.BumbingInspector"
6.Other
' COMMONWEALTH
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EGEZTRICIAN
ISSUES THE FOLLOWING LICENSE
A ,A .RAG JOURNEY' N .ELECTR 1.0 I Ahl
,JUST.I N T HART � �
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122 k OOL ST
Po fOX' 74
ELANp MA o1834 0074
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