E-19-1176 "^
4 „ Commonwealth of Official Use Only
ftirt Massachusetts Permit No. BLDE-19-001176
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
rRev.I/07j
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC),527 CMR 12.00
(PLEA SE PRINT ININK OR TYPE ALL INFORMATION) Date:8/28/2018
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) 5 GLENWOOD ST
Owner or Tenant WACKROW JEAN M(LIFE EST) Telephone No.
Owner's Address 5 GLENWOOD ST,WEST YARMOUTH,MA 02673
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 0 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Replacement boiler.
_ 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- ❑ 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 1 No.of Detection and
_.. Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons _—
No.
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 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 ❑ 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: WAYNE B SCHMIDT
Licensee: Wayne B Schmidt Signature LIC.NO.: 33699
(If applicable.enter"exempt"in the license number line.) Bus.TeL No.:
Address:222 WILLIMANTIC DR.MARSTONS MLS MA 026481929 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) 0 owner 0 owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE:$50.00
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a.lIf , Occupancy and Fee Checked
• \ y.. BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Cocle,.(i'+f5G),527 FMR I�.IiO
(PLEASE PRINT IN INK OR ALL INFOR ION) Date: S(() rOJwf 7 I\I 1 (OJ
City or Town of: 1111/1101/
To the Inspector of Wires:
By this application the undersign gives notice of his or her int tion to performtethe electrical(work described below.
Location(Street&Number) 5 ex\1W, ('} O .i u W a y i7 celc
Owner iorTenant 3:e—...CA—r\ U3Ctul.i -cej(AJ Telephone No. 7s7- OKca'
Owner's Address --------
Is this permit in conjunction with a building permit? Yes ❑ No'$ (Check Appropriate Box)
Purpose of Building 1)W_e•\\ \A!^ Utility Authorization No.
Existing Service_ Amps : / Molts Overhead ID Undgrd❑ No.of Meters
New Service Amps / Volts Overhead 0 Undgrd ❑ No.of Meters
Number of Feeders and Ampacity r �
catiLk)and Nature of Proposed Electrical Work: ) I rc '�cpL&c.e VNj.e,y‘jr
1Ler V
Completion of the following table may be waived by the Inspector of Wires.
otal
No.of Recessed Luminaires No.of CeI.-Susp.(Paddle)Fans • Tra of
Transformers KVA •
KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
• No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting
grad. grad. Battery Units
No.of Receptacle Outlets No.o rs FIRE ALARMS No.of Zones
No.otSwitches No.of Gas Burners V No.of Detection and
Initiating Devices
No.of Ranges No.oI Air cond .Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons _TCW_ No.of Self-Contained
P Totals: ' —• Detection/Alerting Devices
No.of Dishwashers Space/Area HeatingKW' Local0 Municipal ❑ Other
P Cyonnection
No.of Dryers Heating Appliances KW Security
No, f Devices or Equivalent '
No.of Water No.of No.of Data Wiring:
Heaters KW Signs Ballasts No.of Devices or Equivalent •
No.Hydromassage Bathtubs No.of Motors Total HP Tei No.of Devices or Equivalent
OTHER: •
Attach additional detail if desired or as required by the Inspector of Wires.
Estimated Valu civmL c rki (When required by municipal policy.)
Work to Start: O� 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 0 (Specify:) -
I certify,under the pains and na s ofveriurr,that the Inform donon this l'anion{s true and comptetu�,^ rep?
• FIRM NAME:_ WAYNESCHMIDT V5 (�—' LIC.NO.: s(O
Licensee: ELECTRICIAN Signature `�J LIC.NO.:
222 WILLIMANTIC DRIVE g
(Ifapplicable.ente MARSTONS MILLS, MA 02648 , Bus.Tel.No. 3Di 7 07/
Address. (508)428.7747 Alt.Tel.No.:J D / f
*Per M.G.L.c. 147,s.57-61,security work 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 ❑owner's agent.
Owner/AgentPERMIT FEE:$
Signature Telephone No.