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Home My WebLink AboutBLDE-19-000608 Commonwealth of Official Use Only E�' Massachusetts Permit No. BLDE-19-000608 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked "' (Rev.l/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:7/31/2018 _ 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) 52 WILFIN RD Owner or Tenant HEWITT MARK A TRS Telephone No. Owner's Address BURNHAM MELISSA M TRS,58 WATER ST,MILFORD,MA 01757 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: 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 ❑ - o No.of Emergency Lighting Arnd. 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 ❑ Municipal ❑ Other: Connection No.of Dryers Heating Appliances KW Security Systems:' No.of Devices or Equivalent No.of Water 1 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 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,secunty 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:$50.00 O1 SL lel, 21(8 ee_. Commonwealth o/lrtadoackidai1d Opii Only,,, / I s t c7 Permit No. e")...4 ( C = The artment o/Dire Serviced + le ( P Occupancy and Fee Checked p BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1 / ZS0 I p City or Town of: YQ(rn oil To the Inspector of Wires: By this application the undersigned gives notice o/f his or her'Hien ton to performfAthe electrical work described below. Location(Street&N�u bfe_r) 5a kJ, ITlr Jot1T� Y6Vrr1rttr 50$y136 _ Owner &sA Address �1UVV`r MJ Ike — Telephone No. Owner's Address (Q` A q,—Pr sS.rto •,�• • "M,t �(^ 5ll Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building i)\w-(III ftG' Utility Authorization No. Existing Service Amps J/ Volts Overhead❑ Undgrd❑ No.of Meters New Service _ Amps / Volts Overhead❑ Undgrd El No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: • E Ler Jen( wtA—i'r i4 o k` 14159411 Completion of the following table pray be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Sus . Paddle Fans No.of Total . P (Paddle) Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimmin Pool Above ❑ In- ❑ 1Vo.orEmergency 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.Inbeten Initiatinggon Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons _ IIeat Pump Number Tons K__W__ No.of Self:Contained No.of Waste Disposers Totals: — — Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Connectionlunicipal ❑ Other P No.of Dryers Heating 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.Ilydromassage Bathtubs No.of Motors Total IIP 3`el No.ofDeiiceso ors l 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. O CHECK ONE: INSURANCE Er BOND 0 OTHER 0 (Specify:) I certify,under the pains and penalties of perjury,that the Information on this application is true and complete. Cr ,. FIRM NA KF tor°SLow putrn3i'ofv a' 4e //1 I' , LIC.NO.: (3/L '— Licensee: (OI42QM,tLV( ) Signature / LIC.NO.:a182Y (Ifapplicable,entyr `exem t' in the license number line.) Bus.Tel.No.•400.394.771 CD C O Address: ' /Ltftici1/429 6I1L 21 `5ott1� 1(14tiotett•], rife 0)-0:47- Alt.Tel.No.: rV *Per M.G.L.c. 147,s.57-61,security wort(requires Department of Public Safety"S"License: Lie.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)❑owner 0 owner's agent. ¢ Owner/Agent Signature Telephone No. PERMIT FEE: $ T • •(7. t_V/IflflVIf.•uns•sf,J {.1MJJYYIIIIJYNJ 1 =ft=it= t Department of Industrial Accidents sth=1Office of Investigations ' =17� 600 Washington Street Boston,MA 02111 .5www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly - 01 Name(Business/Ortganization/Individual): Ef.Wtns1ON! Q10inkto;.nej• g vit0.� -`n e., 1nCI Address: B' QPoti tvi C.i4e— 0 City/State/Zip: Scxs Phone#: 508-399-1179 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 :.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. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 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' comp. insurance required.] 13.0 Other thy applicant that checks box 41 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. //�� tsurance Company Name: Arypv,J rtJl-tlt✓1 ova vi olicy#or Self-ins.Lic.#: 1 S a I Pc • Expiration Date: 1--I " DO19 Ib Site Address:m2.3 CeAnnAcvl vre0_U11 AAR1 CHe3 111 City/State/Zip: cog k,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 tvestigations the DIA for insura overage veri a on. do hereby certify un re ains a penalties o p jury that the information provided above is true and correct i�natuT� Date: Ian 711 9.017 hone#: STA:354• -mg 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#: