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Home My WebLink AboutBLDE-19-000661 Il Commonwealth of Official Use Only a Massachusetts Permit No. BLDE-19-000661 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked tRev.1/07) 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:8/1/2018 City or Town of: YARMOUTH 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) 107 WIMBLEDON DR Owner or Tenant CHRISTODOLOU CHRISTA J Telephone No. Owner's Address TESSMANN WINFRIED, 107 WIMBLEDON DR,WEST YARMOUTH,MA 02673 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 0 No.of Meters New Service Amps Volts Overhead 0 Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Replacement water heater. 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 No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting 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/Alertine Devices No.of Dishwashers Space/Area Heating KW Local 0 Municipal 0 Other: Connection No.of Dryers Heating Appliances KW Security Systems:" No.of Devices or Equivalent No.of Water I KW No.of No.of Data Wiring: Heaters Stens 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: Inspection 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 0 BOND 0 OTHER 0 (Specify:) /certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: RICH M MELVIN Licensee: Rich M Melvin Signature LIC.NO.: 21829 (If applicable,enter"exempt'in the license number line.) Bus.Tel.No.: Address:8 REARDON CIR, S YARMOUTH MA 026641207 Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: OWNER'S INSURANCE WAIVER:I am aware that the License does not have the liability insurance coverage normally required by law.But signature below,I hereby waive this requirement.I am the(check one) 0 owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$50.00 takb 8NJie 1,.ommanwealth.oirriaaeachueeifa OfficialUseOnly0 2t c;� c7 PemutNo, •nth ? 1Jepartmant 0/..tire Services E,—.1 , occupancy and Fee Checked ``'� BOARD OF FIRE PREVENTION REGULATIONS [Rey.1/07] peaveblank) • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ' All work to be performed in accordance with the Massachusetts Electrical Code(MEC 527 12.00 (PLEASEPRINTIII INK ORT E� I TIM �l Date: O/ P7 /g City or Town of: fdc S% To the Inspec or of Wires: By this application the undersign gives notice of his or er intention to perform the electrical work described below. Location(Street&Number) I1 � 0 b is jV E r g Owner or Tenant f7ZI,p 'r`GSS/Ii/t' t) Telephone No.77 "7 / Owner's Address .S//ot Lr' Is this permit in conjunction with a building permit? Yes ❑ No Er (Check Appropriate Box) Purposeoffuilding arJSLL41-6-- Utility Authorization No. Existing Service_ Amps ' / Volts Overhead 0 Undgrd 0 No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters __ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ELECr/2JC- • GM-Tale--- . Salt a . Com-tenon a the ollowin:table in, be waived b the far,cctor a fres. . o.of ota No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers EVA No.of Luminaire Outlets No.of Hot Tubs Generators EVA. Above In- No.ofEncy Lighting No.of Luminaires Swimming Pool grnd. 0 grnd. 0 Battery Units No.of Receptacle Outlets No.of Oil Burners FERE ALARMS INo.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Q Heat Pump Number tons KW No.ofSelfContained 1� No.of Waste Disposers Detection/Alerting Devi Totals: ces Municipal 0Other No.of Dishwashers Space/Area Heating KW Local❑ Connection Appliances ICW security Sysms Heating No.of Dryers gApP No.of Devices or Equivalent No.of Water No.of— No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent 0.0 OTHER: OCfNAttach additional detail ifdesirea or as required by the Inspector of Wires. (� Estimated Value of Electrical Work: (When required by municipal policy.) NWork 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 VT 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 RI BOND 0 OTHER 0 (Specify:) • /certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FHtMNAlV�: �F to 0.251.00 •L to 4. fI'Bl' r LIC.NO.: _'.2 l� cK -- MC.NO..9l5'2`? L[censee: tGFFAr�� /14 ALV IN Signature�� ! Bus.Tel.No. Kra (If applicable,ent "exem4"Inthe Icense nu :berline.) 4, Address: ' L' 410 IOiU fiat vu, ; 'id•a t4 ' 0 k 4?_ Alt.Tel.No. ---- *Per M.O.L.c.147,s.57-61,security wor 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 tequired by law. By my signature below,I hereby waive this requirement. I am the(check one 0 owner 0 owner's a ent. Owner/Agent PERMIT FEE:$ Signature Telephone No. . g 1 �.. • • The Commonwealth of Massachusetts 6t Department oflndustrialAccidents 1 Congress Street,Suite 100 N . Boston,MA 02114-2017 www.massgov/dia Workers'Compensation Insurance Affidavit:General Businesses.. TO BEFILED WITH TEM PERMITTING AUTHORITY. A. alicantInformation Please Print Le i±ibI • Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO.,INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664. Phone#:508394 7778 Are you an employer?Check the appropriate box: Business Type(required): 1.p I am a employer with _employees(full and/ 5. 0 Retail or part-time).* • • 2.❑ I am a sole proprietor or partnership and have no 6. ORestauranfBazBahngEstablishment 7. 0Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capachy. 3.❑ [No workers'comp.insurance required] 8. 0 Non-profit We are a corporation and its officers have exercised 9. 0 Entertainment • • their right of exemption per c.152,§1(4),and we have 10.0 Manufacturing 4.❑ no employees.[No workers'comp.insurance required?* We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees.[No workers'comp.insurance insurance req.] 12.0 Other *Any applicant that checks box Ni must also fill out the section below showing their workers'compensation policy infoimation **lithe corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box 0. ' Iamanemployer that Isproviding workers'compensation insurance for my employees Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Andress:23 COMMONWEALTH AVE City/State/zip: CHESTNUT HILL,MA 02467 Policy#or Self-ins.Lic.#1821AExpiration {y ate:Attach a copy of the workers'compensation policy declaration page(showing the policy nu ber0and 1/2expiration 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. /do hereby certi :.• ;,enalttes o perjury that the information provided above is true and correct Sly'ature: 4 -..t°. Date: °7 'hone;•508-394-7778 • Official use only. Do not write In this area,to be completed by city or town official City or Town IssuingAuthority(circle one): • Permif/License# • 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: wwwtmass.gov/dia