Fill in a Valid Massachusetts Permit Electrical Form

APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK

All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00

By this application the undersigned gives notice of his or her intention to perform the electrical work described below.

Number of Feeders and Ampacity

Location and Nature of Proposed Electrical Work:

Completion of the following table may be waived by the Inspector of Wires.

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.

I certify, under the pains and penalties of perjury, that the information on this application is true and complete.

OWNER’S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally

The Commonwealth of Massachusetts

Department of Industrial Accidents

Office of Investigations

600 Washington Street

Boston, MA 02111

www.mass.gov/dia

Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers

Applicant InformationPlease Print Legibly

Name (Business/Organization/Individual):______________________________________________________

Address:__________________________________________________________________________

City/State/Zip:_____________________________ Phone #:________________________________

*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.

†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 their workers’ comp. policy information.

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:____________________

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 under the pains and penalties of perjury that the information provided above is true and correct.

Signature:Date:

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 5. Plumbing Inspector

6.Other ______________________________

Contact Person:_________________________________________ Phone #:_________________________________