Massachusetts Permit Electrical Form – Fill Out and Use This PDF

APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK

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

(PLEASE PRINT IN INK OR TYPE ALL INFORMATION)		Date:
City or Town of:		To the Inspector of Wires:

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

Location (Street & Number)

Owner or Tenant

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

No. of Meters

New Service

Amps

/

Volts

Overhead

Undgrd

No. of Meters

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.

	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
				Above		In-	No. of Emergency Lighting
	No. of Luminaires			Swimming Pool grnd.		grnd.	Battery Units
	No. of Receptacle Outlets			No. of Oil Burners			FIRE ALARMS		No. of Zones
	No. of Switches			No. of Gas Burners			No. of Detection and
							Initiating Devices
	No. of Ranges			No. of Air Cond.	Total		No. of Alerting Devices
					Tons
	No. of Waste Disposers			Heat Pump Number	Tons	KW	No. of Self-Contained
				Totals:			Detection/Alerting Devices
	No. of Dishwashers			Space/Area Heating KW			Local	Municipal		Other
								Connection
	No. of Dryers			Heating Appliances		KW	Security Systems:*
							No. of Devices or Equivalent
	No. of Water	KW		No. of	No. of		Data Wiring:
	Heaters			Signs	Ballasts		No. of Devices or Equivalent
	No. Hydromassage Bathtubs			No. of Motors	Total HP		Telecommunications Wiring:
							No. of Devices or Equivalent
	OTHER:
				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 coverage is in force, and has exhibited proof of same to the permit issuing office.

CHECK ONE: INSURANCE

BOND

OTHER

(Specify:)

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

FIRM NAME:							LIC. NO.:
Licensee:			Signature				LIC. NO.:
(If applicable, enter “exempt” in the license number line.)						Bus. Tel. No.:
Address:						Alt. Tel. 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.
Owner/Agent		PERMIT FEE: $
Signature	Telephone No.

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 #:_________________________________