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Home My WebLink AboutBLDE-18-007357 • +/ Official Use Only Commonwealth of 0 Massachusetts Permit No. BLDE-18-007357 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked f Rev.I/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:6/27/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 115 CAPT SMALL RD Owner or Tenant PAUK-DRAKE CHRISTINE Telephone No. Owner's Address 115 CAPT SMALL RD,SOUTH YARMOUTH,MA 02664 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 ❑ 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 generator. Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-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 ❑ In- o 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 ❑ 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: 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: 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 ofperJury,that the information on this application is true and complete. FIRM NAME: RICH M MELVIN Licensee: Rich M Melvin Signature LIC.NO.: 21829 (Ifapphcable,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 Telephone No. PERMIT FEE:$50.00 Ca-t — 8(4 s e_6_ F ,� C [ Official Use Only 357 i `� ommonwect o! eamac wells pi a 9 w it cy c7 �a Permit No. (Jrt� t_ ` T epariment o/. ire Serviced AIR!?I 5 Occupancy and Fee Checked \.,..-e:. ,,.' BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Coe C),527 CMR 12.00 (PLEASE PRINT IN INK OR TOPE ALLINFORMATIONJ Date: 14 / I cg City or Town of: (,f yti]Q I1-K To the Inspector of Wires: By this application the undersigned gives notice of his or her'ntention to pe orm th electrical work described below. Location(Street&Number) C g try I A .. .. ,// Owner or Tenant '5 ;14 4, Telephone No. 5(9g 2.44 b21-1. Owner's Address ("V\Q Is this permit in conjunction wil1k a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building N W IOW AV Utility Authorization No. Existing Service_ Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service _ Amps / Volts Overhead D Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 6f()f r,J/ in 5)4/(p f//4 Completion of the following table may be waived by the Inspector of Wires. otal No.of Recessed Luminaires No.of Ceil:Susp•( )Paddle Fans No.of KVA Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires SwimmingPool Above ❑ In- ❑ No.of Emergency Lighting • grnd. grad. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones and No.of Switches No.of Gas Burners No.of Detection on 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:I "' "' Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Municipal o Other P 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 No fDeiceor Wiring:q No of Devices Equivalent OTHER: Attach additional detail ifdesired,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 0 OTHER ❑ (Specify:) /certify,under the pains and penalties of perfury,that the information on this application is true and complete. FIRM NAM Kr U)fflSLDIJ PeAtyf1>tA(o a.• 1tir L' IA-Z . LIC.NO.: 373/G- Licensee:f,1C.-111/1.n M iLv(t) Signature �ti LIC.NO.:9/8n`nd N.) �� (If applicable,entg exempt"in the license number line) 4 Bus.Tel.No.t'O3;:3Q4•7775' l� r__„ Address: 9 /L2,ei7=QoN G//tag 5vutf1 11/4-f�Mourtl, DIW Oy44 Alt.Tel.No.: t� *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. Lch k J's INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally (---• t_r) required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. W 6) Owner/AgentPERMIT FEE: $ CO c-t SignatureTelephone No. a . 1 ,yam _ \ The Commonwealth of Massachusetts =-1_ql Department of Industrial Accidents =AmE _;;MI'= 1 Congress Street,Suite 100 `: Boston,MA 02114-2017 mpt• ;� www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Business Type(required): 1.❑✓ I am a employer with 10 employees(full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. Non-profit 3.❑ 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 no employees.[No workers'comp.insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees.[No workers'comp.insurance req.] 12.0 Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box 41. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address:23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL, MA 02467 • Policy#or Self-ins.Lie.#1821A Expiration Date:01/01/2019 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 certi Ute aps and p�naltirs o perjury that the information provided above is true and correct. Signature: /[/ //� -. . Date: i 13 / / phone#:508-394-7778 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia