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Home My WebLink AboutBLDE-19-000079 I. — Commonwealth of Official Use Only tt ilt‘ Massachusetts Permit No. BLDE-19-000079 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.l/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:7/5/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pertorm the eiec�at work described be w. A ' &Number) 10 WINCHESTER AVE t 47 Location(Street Qf�0 1/2 I v 1 Owner or Tenant Telephone No. Owner's Address 6 01059 Is this permit in conjunction with a building permit? Yes ❑ 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 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install generator. Completion of the followmg 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 1 KVA No.of Luminaires Swimming Pool Above caIn- 1:1No.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/Alerting 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 KW No.of No.of Data Wiring: 1 Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: I • 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 ❑ (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 CR,S YARMOUTH MA 026641207 Mt.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) ❑ owner 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$50.00 6)--e3.. e(, Jie - commonwea&of aeachwelle Q a � 7 yPermit No. "—Ft?' lbwc a-e? apartment oPire Servicee )mPuOccupancy and Fee Checked ,z sI BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/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 (PLEASE PRINT IN INK OR WeiALLINFORMATION) Date: 61,77o11 (6 City or Town of: tkI't/L 0 Vb.\ To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work describ below. Location(Street&Number) `,,Jin.Ckec-ef Rif{hvF. Wt5b'1 cmevRN 1613 Owner or Tenant IAKr0t I,I v]j Telephone No777-7/4( crif9ti Owner's Address Slnwnit. Is this permit in conjunction with a building permit? Yes ❑ No Er (Check Appropriate Box) Purpose of Building Dwell Irl f'] Utility Authorization No. Existing Service Amps J / Volts Overhead❑ Undgrd❑ No.of Meters 1 New Service _ Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity n Location and Nature of Proposed Electrical Work: G e miTA-Eole- I✓t)alt I I Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Sus . Paddle Fans No.of Total y P (Paddle) Transformers KVA V"- No.of Luminaire Outlets No.of Hot Tubs Generators KVA 0 No.of Luminaires Swimmin Pool Above ❑ In- 0 No. E of mergency Lighting g grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones s No.of Switches No.of Gas Burners No.of Detection and Initiating Devices ��}- No.of Ranges No.of Air Cond. TonTota No.of Alerting Devices J No.of Waste Disposers Heat Pump[Number„ Tons -KW No.of Self-Contained P Totals:I ---- Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local o Municipal ❑ Other P Connection 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 Equivalent No.II dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: Y g No.of Devices or Equivalent OTHER: 00 Attach additional detail ifdesire4 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 ErBOND 0 OTHER 0 (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAMM, KF IJ/OSLO&) PLttt'/T'viiv(n d- fie 79 ' 111-K • LIC.NO.: `ale, Licensee:' (A(( .Q Mt1- (IU Signature f/fes � - LIC.No.:9/57? (If applicable,enter"exploit in the license number line.) V Bus.Tel.No:Cog.39�1'77 Address: 5 iter- ON Gtltat 5vittti yi4�hlot tr+l, titre Oyb6 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 PERMIT FEE:$ Signature Telephone No. 16 Cr yw \ use aiv$$$$$$rroualn✓ .L1,4640..7•41•11•8444.454 4: ' Department of Industrial Accidents l zi=ift Office of Investigations "n= 600 Washington Street ri='° Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C /� 1 Please(� Print Legibly Name(Business/Organization/Individual): a.C.Wt,r,SI0,,,J QLi.' Jo nt .& <4CcL%'✓vq, `e•, Address: $ Gorky) C;rJe- a City/State/Zip: So.s r kfl NPc Phone#: ' 135- Y19-117SI Are you an employer?Check the appropriate box: Type of project(required): 141 am a employer with 20 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 0 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. 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions i.❑ 1 ant a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§I(4),and we have no 12.9 Roof repairs insurance required.]t employees. [No workers' 13.❑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 isurance Company Name: / %t ,•� rLh'tto_k ^1(p n CP_ Cq ant\ny olicy#or Self-ins.Lic.#: ( $al I '1 Expiration Date: (—[ aOI9 lb Site Address:;23 ch w Pub{h CFQS rn�1 City/State/Zip: Oa'4 b 7 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.•t a copy of this statement may be forwarded to the Office of ' • ivestigations the DIA for insura. overage verif a,on. • do hereby certify un re ains a /penalties o p• jury that the information provided above is true and correct. ignat& : Date: [;131 ) a017 hone#: cot '35`I- 797 ' 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#: t