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Home My WebLink AboutE-19-723 Y`'ar• Commonwealth of Official Use Only iiii r� Massachusetts Permit No. BLDE-19-000723 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked IRev.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 INFORAL4TION) Date:8/6/2018 City or Town of: YARMOUTH 'A To the Inspctor of Wires: By this application the undersigned gives notice of his or her intention to perform t1ectrical work described hflAvy _ I Location(Street&Number 10 SOUTH ST I �.-eC1C•...tJ I/7J 2]' Owner or Tenant MCNERNEY RITA T(LIFE EST) Telephone No. Owner's Address 10 SOUTH ST,SOUTH YARMOUTH, MA 02664 Is this permit in conjunction with a building permit? Yes 0 No ❑ (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 NC system. 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- CINo.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 Initiatinz 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/Alertina 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 MW No.of No.of Data Wiring: Heaters Sins Ballasts No.of Devices or Equivalent No.Ilydromassage Bathtubs No.of Motors Total IIP Telecommunications Wiring: No.of Devices or Equivalent OTIIER: Attach additional detail tfdesired 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) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$50.00 Commonweall.oI rr/assachasetls Official Use r rrpi c'y ec77 n Permit No. 09 072e' `` Theparlment o/,vire Serviced t "" _ •` Occupancy and Fee Checked `? BOARD OF FIRE PREVENTION REGULATIONS ev.1/07 • ��„� (R ) (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 C 12.00 (PLEASE PRINT IN INK OR TYRE�ILL INFO 2MATION) Date: C6 !. City or Town of: WW1(J-h To the Inspector of Wires: By this application the undersigned:fives notice .1 his or her intention to perm the electrical work described below. Location(Street&Nu ber) I Y V .e`� 'aG su A 0 J f1-1 , 0 �6'0 TelephoneNo. 770"& 57?/627 Owner or Tenant ' 1 f (n [V�p(.�t►'�I Owner's Address C)Avl_c Is this permit in conjunction withtuildingpermit? Yes ❑ No [ (Check Appropriate Box) Purpose of Building bw.eIaliIiV Utility Authorization No. Existing Service_ Amps / J Volts Overhead 0 Undgrd❑ No.of Meters New Service _ Amps / Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity �/ LocationdNature f Proposed Electrical Work: Ai I (On(/ , kl 0{Z/0, S 1 C 14 Com.letion o the ollowin:table m be waived b the Ins. ctor o Wires. `o.o Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimmm Pool Above ❑ In- ❑ 'No.of Emergency Lighting • _ g grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones in and No.of Switches No.of Gas Burners No.orDetectInitiating g Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Dis Disposers Heat Pump Number Tons _ K__W No.ofSelf-Contained P Totals:I II .. _ Detection/Alerting Devices Other No.of Dishwashers Space/Area Heating KW Local 0 Municipal Connection r-, No.of Dryers Heating Appliances r -security fDsevv Devices No.of Systems or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Eiviyalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP 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. HINSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless --r. the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The ,.• t f undersigned certifies that such coveragetis in force,and has exhibited proof of same to the permit issuing office. 7 �0 „ , CHECK ONE: INSURANCE (y1 BOND 0 OTHER 0 (Specify:) --.;_ I certify,under the pains and penalties of perjury,that the information on this application is true and complete. N FIRM NA KF lf)(NSI4W PGtt 'I�LN(v °` 4S* lam.___ LIC.NO.: Sly C c Licensee: ICtM(ZD M gat& Signature _.,./ . LIC.NO.:9 i Sen —) L..l (If applicable,ent. "exern.t"In the l•cenlse-nu�;ber line.) Bus.Tel.No.•5.0g'39 q'77 18. — `'�iIT-' Address: : " ithaloP ItGLt V. La dr L r 0 _ Alt.Tel.No.: *Per M.C.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 • required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. • •a use •.v..o..v..mous..•v., avww..uswro.sa Department of Industrial Accidents t_.: j �t Office of Investigations t 600 Washington Street "'iii--- aBoston,MA 02111 vre jrive www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E•C•Wtyt$iOw �t!„y�' g {0.�; Ce•, InC. Address: g Keosltin ci;R,le. City/State/Zip: Solt Vcrr..0Jt MA- Phone 4: 501-399-1'77Si XAre you an employer?Check the appropriate box: Type of project(required): I am a employer with '/0 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction ❑ I am a sole proprietor or partner- listed on the attached sheet.S 7. 9 Remodeling ship and have no employees These sub-contractors have 8. 9 Demolition working for me in any capacity. workers'comp. insurance. 9. ❑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 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' comp.insurance required.] 13.❑Other • my applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. iomeowners 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. xm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. //�� - f surance Company Name: irlYi'pv,.s C1u�-uo) jelTrotrent n Cc. Cpl. tai llicy#or Self-ins.Lie..^^#: $Zt I pr • Expiration Date: —I a171� .b Site Address:a3 r.Acvn w•eo.J111 /lithe/ Ccsc411. i1 U City/State/Zip: Oay lc ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). tilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a to 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 'up to$250.00 a da a:ainst the violator. Be advised t •t a copy of this statement may be forwarded to the Office of vestigations • the DIA for insure• ' overage veri j on. do hereby certify un • • penalties o 7jury that the information provided above is true and correct atilt: -• c Date: [d 1 aol Ione#: WY 35`1. 797$ 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#: