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Home My WebLink AboutBLDE-19-000724 ^-� *1°' Official Use Only -' f.�a'. gt�� Commonwealth of k`E•.TMassachusetts Permit No. BLDE-19-000724 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked JRev.1/07] 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 MINK OR TYPE ALL INFORMATION) Date:8/6/2018 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) 45 TALL PINES DR Owner or Tenant GAFFNEY JAMES Telephone No. Owner's Address 45 TALL PINES DR,YARMOUTH PORT, MA 02675 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: Replacement oil burner&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 0 In- ❑ No.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners 1 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 Disposer 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 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 f 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 (lf 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 Telephone No. PERMIT FEE:$50.00 gfroIie tita A CommnnweaCh o/radoac Luded Official Use Only $ tPermit No. aq - 07 �. , department oflire Serviced i , I€ Occupancy and Fee Checked . 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 C.IR 12.00 (PLEASE PRINT IN INK OR TYPF ALL INFORMATION) Date: 1 / a r 1 ch City or Town of: Y&1'$J10 If .11/\- — To the Inspector of Wires: By this application the undersignedgives notic ahi�to,r her intention to p rpf/prm the ele trical ork escri'ed elow. Location(Street&Number) 45 1 Pi 06 t f Y yjOu ir-F ,•` 2' 5 Owner or Tenant ,1-0 11 (ZfI 1(9 Telephone No.-36) q i Owner's Address SCMQ Is this permit in conjunction with a building permit? Yes ❑ No Er (Check Appropriate Box) Purpose of Building t.),),e(11trir1 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 1 Lo ation a d Nature of Proposed Electrical Work: ode( bolt i' 0\46 in 1-wr,(4•f e/ • ?oder per C04414-c4- Com.letiono the ollowin:table ma be waivedb the Ins'-etoro Wires. `o.o Tata No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.of Emergency Lighting No.of Luminaires Swimming Pool grnd. ❑ grnd. ❑ BattyUnits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of DInitiaattingon and ng Devices No.of Ranges No.of Air Cond. Tons' No.of Alerting Devices No.of Waste Disposers Heat Pump I Number'Tons. LRW Nb.of Self-Contained p Totals: l -� Detection/Alerting Devices unic MOther No.of Dishwashers Space/Area Heating KW Local❑ Connection ipa ❑ No.of Dryers Heating Appliances KW Security SDsvices Y No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent 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. 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. r CHECK ONE: INSURANCE WJ BOND 0 OTHER 0 (Specify:) _ 1 t^ I certify,under the pains and penalties of perjury,that the information on this application is true and complete. ,,/� (_"1 'llJ FIRM NA $r to IVSLOW ' ,//p. . 6• s j r LIC.NO.:__W-- ,....-.., L 1 V ` ` v C . Licensee: �t LIC.NO.:91 B O �((,({�(Ln M�Lvfly Signature �/ , ,- (If applicable,enj"exem t�' in the license number line.) 4 Bus.Tel.No.:SdB•3 914'777r5 `0c. Address: 13 AZ/t7'I/ON [riles `JUit1ii yfritiouttlr ehe Dy4� Alt.Tel.No.: st to "Per M.C.L.c. 147,s.57-61,security world requires Department of Public Safety"5"License: Lie.No. 'gyp O OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally 4r C-1 required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner 0 owner's agent ta_ ii' Owner/Agent I PERMIT FEE: $ Signature Telephone No. 6 • £In VVIINIIVIf IYiM/•I•RAJ IIJINJ44I0.,J.ee., Department of Industrial Accidents Imo ' •—. , ) =,:'fir; Office of Investigations •_;`:`_ 600 Washington Street Boston,MA 02111 •t`; www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organiration/Individual): E.c.Winstow Pl0„yto' A. 4{0.� (1.) InC. Address: g &eo kv, ClIrrj2- City/State/Zip: So,s%r `jcre.-.0,,(t-, HA- Phone#: '508-399-11'7S/ 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 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.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 9 Demolition working for me in any capacity. workers'comp. insurance. o workers'comp.insurance 5. 9. ❑Building addition 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.] 13.0 Other Lily applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • domeowners 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. nn an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. surance Company Name: Ant.-1 C{Ct-ue—A -f n Ca ‘bny slicy#or Self-ins.Licc.(.^^#: 1 S as I /te Expiration Date: i—( — aO(9 ib Site Address:a3 ,v\ n w2oJ4.h Att.,/ 0.,e3W1.. Oral City/State/Zip: O0'4 107 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 a'on. io hereby certify un e �ns a penalties o p•jury that the information provided above is true and correct. griatuto: Date: (a)311 a017 - lone#: SrL 311- 7771? Official use only. Do not write ht 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#: