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Home My WebLink AboutBLDE-19-001251 . it. i .� Commonwealth of Official Use only Massachusetts Permit No. BLDE-19-001251 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked JRev.l/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:8/29/2018 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) 158 THACHER SHORE RD Owner or Tenant AYLMER DAVID H Telephone No. • Owner's Address HUCKINS JOAN E,PO BOX 54,YARMOUTH PORT,MA 02675-0054 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 ❑ Undgrd 0 No.of Meters New Service Amps Volts Overhead ❑ Undgrd ❑ 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- 1:1No.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 Alr 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 0 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 ❑ 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 (7f 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 elffel m _ommonwea a adsac ase �•�^ — ZS- 1 I 0 Ir_(t cy giro pp Permit No. &IC_l/ C'/�`J tL 6 1Jeparfineenl of ire—cervical111 Occupancy and Fee Checked . 'e '1 BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (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 TT'PFALL INFORMATION) Date: 3 / 2, Cl City or Town of: Ya f'm 0 u -Fin To the Inspector of Wires: , / �7 By this application the undersign• :ives notice of his sr her intention • •erform the e c.ica work described i to of O) b 1 5 Location(Street&Number) e • A A l (' . !/ Owner or Tenant paid ( AU or Telephone No. 50s-36).936o Owner's Address c[tVYlk Is this permit In conjunction with,a building permit? Yes 9 No E (:heck Appropriate Box) rB Purpose ouilding h w t IA,n.CA Utility Authorization No. Existing Service_ Amps J/ Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead 9 Undgrd 9 No.of Meter's _ Number of Feeders and Ampacity , Location and Nature of Proposed Electrical Work: (j oi5 15o f tr I v15t II' )j &h Com.letion o the ollowin:table in be waived b the Ins.ector o Wires. o.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- rho.of-Emergency Lighting No.of Luminaires Swimming Pool grnd. ❑ grnd. 0 Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS. No.of Zones Et No.of Switches No.of Gas Burners No.ofDetectionic InitiatinggDeva Tota No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW_ No.of Self-Contained p Totals: — Detection/Alerting Devices M No.of Dishwashers Space/Area Heating KW Local 0 Connectionunicipa ❑ Other ASNo.of Dryers Heating Appliances KW ecNo.ofDy svices No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters 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 officer V CHECK ONE: INSURANCE l BOND 0 OTHER 0 (Specify:) ,v---) c I certify,under the pains and penalties of perjury,that the information on this application is true and complete. C� �> FIRM NA :: cto ostok) • -,U i. . a- a r - •• . LIC.NO.: `i - tD� Licensee: r '-A LIC.NO.a187`7. _^ ([,�(Ln /•t�ZVftU Signature n `' (lfapplicable,enr "ezeinit"inthe 'cense nu,berline.) / Bus.Tel.No.•408.39q•'�7� Address: ; /IL./at0 U. is ;dr 14• t-1 ' a _ Alt.Tel.No.: 8 *Per M.G.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 Se the liability insurance coverage normally CI— 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. • �b 1°�C ' a l.n- VVIINIWI.,y1.. ,,V•,2 VA MOJJb4IMOS,'O MOS,'SO 1 h= Department oflndustria[Accidents l _,z' �,_.t Office of Investigations __ '; 600 Washington Street Boston,MA 02111 • `_' www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information /� 11 Please((lPrint Legibly Vame(Business/OrPganization/Individual): E.c.Wtr'sslet. �u.s.Si. g O{0.1'rf \e} jilt/ Address: ' ' &eodttn Gta�. . My/State/Zip: Satin Ycro.,e,,,kn t4Ar Phone#: 506.399-117S/ re 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 0 I am a sole proprietor or partner- listed on the attached sheet.t 7• 0 Remodelng ship and have no employees These sub-contractors have 8. ❑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.❑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 • iy applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. • >meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. In an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site rrmation. Afro‘....)uranceCompanyName: /�1 ...s fiot-ue.,% of nCC. Canary icy#or Self-ins.Lic.^#: 18 A I Expiration Date: (--1 - ?019 •e Site Address: 3 �rinmen µeJ4-t$ Ad-e1 cits J4. Atli City/State/Zip: 0,)4167 ach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a t 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 tp to$250.00 a da a:ainst the violator. Be advised t i.t a copy of this statement may be forwarded to the Office of estigations . the DIA¢or insura. ' overage veri"on. I hereby certify un , - . penalties o 'jury that the information provided above is true and correct. tatuT: Vir , Date: 1a i ani' ne#: ..cbL 311`1. 797E 7fficial use only. Do not write in this area,to be completed by city,or town official . • ity or Town: Permit/License# 'ssuing Authority(circle one): • ..Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector i.Other l'ontact Person: • Phone#: