HomeMy WebLinkAboutWire Permit - Permits #13014 - 52 NORTH CROSS ROAD 12/23/2014 ........
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Commonwealth of Massachusetts Official Use Only
Department of Fire Services
Permit Na.
BOARD OF FIRE PREVENTION REGULATIONS
(Please add zip pptyme -P electrician'- Occupancy and Fee Checked
contract# & bid permit#1 if applicable.) (Rev. 1/071 (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
(13LFSASF_ PRINT IN INK OR TYPE ALL INFOkMA TON)
Date:
City or Town of:
To Me i �pector qf'mires:
Bythisapplication tile undersi _[FI—telltion to perfbirril the electrical work described below.
gned gives notice of his or her
Location (Street& Number)
Owner or Tenant
Owner's Address Telephone No.
Is this permit in conjunction with a building permit? V eS Na E]�(Check Approp'riate Box)
Put-pose of Building Utility Authorization No.
Existing Service Amps Volts Overhead El Undgrd ❑ Na. of Meters
-Nmcw'Scrv�ice Amps Volts Overhead ❑ Undgrd ❑ Na. of Meters
Number of Feeders and Ampacity
L,ocation and Nature of Proposed Electrical Work:
Corn,
o�, tableomao�l
the'"s
o 'It
To.
Inscolor
No. of Recessed Luminaires No.of Ceil.-Susp, (Paddle) Falls 0. 0 f ota
p�
N of
Transformers
is r mers
o Transformers KVA
o. of Luminaire Outlets No. of Hot Tubs Generators KVA
0. of Lull bov
No.No,
Luminai.res Swimming Pool c ❑ In- ❑— 0. 0 merge cy ig ing
grrid. L)rrnd. Battery Units
No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones
No. of Switches No. of Gas Burners 1VOK—OTI-Yetection and
No. of Ranges No. of Air Cond. otal Initiating Devices
I • Tons No. of Alerting Devices
Iie6n 1161111111 " � !��i �� �
Na.
of Waste Disposers I KW__ 14 1 1, 111 � �� :ii—
.7 ed
Totals:Is: 1 !!� _ Detection/Alertln Devi
No. of Dishwashers Space/Area Heating KW Local E] unlelpa ces
-connection D Other
No. of Dryers Heating Appliances KW urity sgtems:
No. of—Water ___No.of Devices or Eguivalent
Heaters K INO-�Of —No. of Data Wiring:
Signs Ballasts No.of Devices or E uivalent
-_ Telecommunications
I-Iyd ro ula ssa ge Bathtubs No. of Motors Total HP I ele1(communications Wiring:
OTHER: No.of Devices or Eguivalent
Estimated Value of Electrical Work: Attach additional detail il"desired, or as required by the Inspector qj'1vjres.
(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 coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE M BOND ❑ OTHER X0 (Specify:) General Liability 12/3 1/14
1 certify, under the pains and penalties of perjury, that the information on this application is true and coniplele.
FIRM NAME: BoiSsonneault Electric Corp
Licensee: LIC. NO.; 11823A
(U'ai.),olicable, enter "exempt"in th Signature e license number line.) _-M C. NO.:-_Av
Address.- 36 ChuckDrive - Dracut, MA 0 1826 Bus. Tel. No.:_Lq_�_�
*Security _�Y�Itcjll Contractor License required for this workapplicable,
Alt, Tel. No.-•_19784459-9977
enter the license number here:
aware that the Licensee does not have the liability insurance covet-age normally
OWNER'S INSURANCE WAIVER: I am I F�i3_pl I'ea�_Ic)_
required by law. By my signature below, I hereby waive this requirement. I am the(check one)F71 owner
owner's agel.11.
Owner/Agent
Signature
Telephone No. ITE;AIIT FEE: $
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The Commonwealth of Massachusetts
Fi;
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www-mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ADDlicant Information Please Print Legibly
Name (Btisitiess/Oi-ganizatioil/iiidividual): BOISSOnnedult Electric Corp.
Address:—36---Chuck Drive-P.O. Box 639
City/State/Zip:— MA 01826 Phone J 978-454-0383
Are you an employer? Check the appropriate box:
am a employer with 4. 1 am a general contractor and I Type of project (required):
/[Q employees (full and/or part-time).* have hired the sub-contractors
2 6. 0 New construction
1 an) a sole proprietor or partner- listed on the attached sheet. t 7. Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers' comp. insurance. 9. Building addition
[No workers' comp. insurance 5. We are a corporation and its
3. E3 required.] officers have exercised their Mff"9tlectrical repairs or additions
1 am a homeowner doing all work right of exemption per MGL I 1.0 Plumbing repairs or additions
myself [No workers' comp, c. 152, §1(4), and we have no 12,go Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13,90 Other
*Any zq)plicant that checks box 41 must fill out(lie section below showing their workers't compensation policy information.
I 101I)COMM'S who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such,
'Cone rz ictor,.that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'conip.policy int"onnation.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Utica NationalInsurance Group
14386559
Policy 11 or Self-ins. Lic. H. LL3 Expiration Date:
Job Sitech Address: I clla
City/State/Zip:
Atta a copy of the workers' compensation policy declaration Page (showing the policy number and expiration (late).'
Failure to Secure coverage as required under Section 25A of MG1., c. 152 cat) lead to the imposition of criminal penalties of
fine LIP to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the forty) 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(to hereb.v certify under the pains and penalties of perjury that the information provided above is true and correct.
Sip—nature -- r— " —11 11-1 1 1 Date:
Phone ii:
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 5. Plumbing Inspector
6. Other
Contact Person: Phone#: