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Home My WebLink AboutBLDE-19-000558 Commonwealth of Official Use Only Massachusetts Permit No. BLDE-19-000558 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.1/071 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:7/27/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pertonn the electrical work described below. Location(Street&Number) 11 CADET LN Owner or Tenant DRISCOLL JAMES P JR Telephone No. Owner's Address 11 CADET LN,WEST YARMOUTH,MA 02673 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 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: Install A/C system. Completion of the following table may he 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 0 In- ❑ No.of Emergency Lighting grnd. grnd. Batten/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. 1 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 KH. No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Enuivalent No.Hydromassage Bathtubs No.of Motors Total II? 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:) I 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 0 owner's agent. Owner/Agent Signature �A Q Telephone No. PERMIT FEE:$50.00 &186171 ts 6EJ UpCdeeDef3 gc6r— flovg1-rbe0 -F1511 "O1O- fNEL tT o c&) j5(-573? Official Use Only _ ommonwea o rueac�iweiie eick—^sS E3 1; p c7 Permit No. (�J nl-. Z Thepariment o/. ire Serviced 1';_,67 d Occupancy and Fee Checked r\--- „4, BOARD OF FIRE PREVENTION REGULATIONS [Rev. (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 (PLEASE PRINT IN INK OR TYFEALL INFORMATION) Date: 1 / ?l{ I City or Town of: Qfi11ou"I-ir‘ To the Inspector of Wires: By this application the undersigned gives notice of hisior her intention to perform the electrical work described below. Location(Street&Number) IiT�(Ot d e f Lavit of tela r -in f Al\ 13 376 Owner or Tenant ZJCAtf C5 !.YI SI'()11 Telephone No. 11 SS66c6 C 7 Owner's Address S&t 141 t Is this permit in conjunction with`?building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building DW Wj I AI 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 r5 /� r Location and Nature of Proposed Electrical Work: Co PY1�// and `Di t( ,(19q /)q9I co Completion of the following table may be waived by the Inspector of Wires. ot No.of Recessed Luminaires No.of Ceil:Sus . No.of T (Paddle)FansVA P Transformers KVA No.of Luminaire Outlets No.of Plot Tubs Generators KVA No.of Luminaires Swimmin Pool Above ❑ In- ❑ No.oft.mergency Lighting • g grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones and No.of Switches No.of Gas Burners No,In�eten Initiatinggon Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW_ No.of Self-Contained P Totals: �u !! Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Municipal 0 Other PConnection No.of DryersHeating Appliances KW -Security Systems:'' No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: heaters KW Signs Ballasts No.of Devices or E quiva lent No.Hydromassage Bathtubs No.of Motors Total HI' Telecommunications 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. Cr 0 CHECK ONE: INSURANCE u BOND 0 OTHER 0 (Specify:) tt kr) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. ` ) ..4... FIRM NAME: K( U)(QSLOW ptven—oW & 6 #1 ,A/LK • LIC.NO.: $l C-- cLicensee: (fjAa/) Mtwut) Signature LTC.NO.:9/En b (If applicable,ent "exem�t""in the license number line) _! Bus.Tel.No$5458.3 94.7778. __ l v Address: /1-2-R )aN GtfLCU SvlttfI tonmotetti, PIIW 07-.4 4". Alt.Tel.No.: *Per M.G.L.c.147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ J010. st 4 �\ En. 1.-•••&&&&&&O/I•Plet.64114.1• J •.... .....,..w , Department of Industrial Accidents _; ] t Office of Investigations _a ae� 600 Washington Street Boston,MA 02111 ..rwww.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information E /� 1 Please(� Print Legibly Name(Business/Organization/Individual): .c.Wtr.5 I OWY[U,.snl7 a' 00- -t 3 L a .r ' \e.} �sit Address: ' k�ear1an C:tC.IQ, d City/State/Zip: Souk 'crw4c3.,kn NAr Phone #: "SOS-394-117Sd Are you an employer?Check the appropriate box: Type of project(required): I am a employer with 70 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time)." have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp. insurance 5. ❑ We area corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 1.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required]t employees. [No workers' 13.0 Other comp. insurance required.] thy 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. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. //�� -� 1 tsurance Company Name: 1kI'p...l C- ki k/02 l wr..k it(ft_ \(1 eZ.n l+ty olicy#or Self-ins.Lic.#: I S a I Pc '1 Expiration Date: I—( " D.09tbSiteAddress: 3 �Mc✓1Vreo-1 11 �1 CPe3 YnII City/State/Zip: Oa)aIto7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a da a ainst the violator. Be advised t rat a copy of this statement may be forwarded to the Office of tvestigations the DIA for insur.r - overage veri aon. do hereby certify un e le ains a I penalties o p•jury that the information provided aboveistrue and correct. ienatuS. : Date: (a) 3 i 1 a01? hone#: SUV 1T-I. 777b' Official use only. Do not write in this area,to be completed by civ 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#: