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Home My WebLink AboutBLDE-19-000993 A a Commonwealth of Official Use Only - t/e Massachusetts Permit No. BLDE-19-000993 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked IRev.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 IN INK OR TYPE ALL INFORMATION) Date:8/20/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pertorm the electrical work described below. Location(Street&Number) 172 DIANE AVE Owner or Tenant MILLER JOHN K TRS Telephone No. Owner's Address MILLER JANE A TRS, 172 DIANE AVE,SOUTH YARMOUTH,MA 02664 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 ❑ 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 distribution panel 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. grad. 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 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 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"or the license number line.) Bus.Tel.No.: Address:8 REARDON CI R, 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 Q(n4e tre- rcra se n _.-- vamm4nwea,.tn of ,,1 amacdept —^ _ 1 a pt ccyy cc77 C� Permit No.PI Vl Tepartment o/Jiro Jerviced *r tea : =f=��_y Occupancy and Fee Checked . 4y -s 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(l IEC),X27 12.00 (PLEASE PRINT IN INK OR TYf ALL INFORMATIO CUA Date: I) 1 7 /D/ City or Town of: 0jfifl 0 k To the Inspector of Wires: By this application the undersigned gives noticeher e �Ve. Sockl y l ) a1 r7fif -t Owner or Tenant Jou Molter Telephone No. SOQ,39411 12. Owner's Address 5(4✓n f Is this permit in conjunction with a building permit? Yes ❑ No D (Check Appropriate Box) Purpose of Building (NQh101 Utility Authorization No. Existing Service Amps J / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meter's Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ( 00 l\rv]Q 1-16/11-9 )10-e 1Cfn? ) /n544II Com'teflon o the ollowin•table in be waived b the Ins sector o Wires. No.o otal 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 Swimmin Pool Above ❑ In- 0 No.ofEmergencyLighting • g grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones No.of Switches No.of Gas Burners No.of Detectionn InitiatinggDevices Tota No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number-Tons_ KW No.No.ofSelf-Contained P Totals: " Detection/Alerting Devices aon l Other No.of Dishwashers Space/Area Heating KW Local 0 CMonnectunicipi ❑ HeatingSecurity Systems:" No.of Dryers Appliances KW No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or E uivalent Te ecommuntcations :ring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desiree(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 C) CHECK ONE: INSURANCE VI BOND 0 OTHER ❑ (Specify:) `amp \p I certify,under the pains and penalties ofperjury,that the information on rias application is true and complete. —� FIRM NA l! to ostok) • _,, p. • 4• /E r - • . LIC.NO.: "31 t r---.t--‘, Licensee: 1C(}R(Lf /n ALV jg) Signature 7 r ' LIC.NO.:9/S?t O (If applicable,ent 'exxemyt'inthe llicen�se�nugmberline.I Bus.Tel.No.:508.3?,4 - V • 77Address: 1 /Lg/i7=,%ON (...4 50014 /11ornt4, (1IQ' Dybro Alt.Tel.No.: ``�� *Per M.G.L.c.147,s.57-61,security wad requires Department of Public Safety"S"License: Lie.No. L.1J 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 0 owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. • Zgla S.Ott. t..r,a.,.w,.ar........,•..uoo....,.l.o....o . . . . r Department of Industrial Accidents )*=---r7--= ==.4006 ..= `,'ltm-.�t Office of Investigations 00= 600 Washington Street N- Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E.C.ww.st L q<0.t�✓�, let (1.) le Address: ' (Zecch:v, Cinch d City/State/Zip: Sou Son Ycrw.oJtn HA- Phone#: '508-399.117C1 Are you an employer?Check the appropriate box: Type of project fiXr1 am a employer with 70 4. 0 I am a general contractor and I 6. 0 New construction _ employees(full and/or part-time)."` have hired the sub-contractors .❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. 0 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. 0 We are a corporation and its 10.0 Electrical repairs or additions • required.] officers have exercised their .❑ 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.❑Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] ray applicant that checks box ill 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. 'onnactors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. //�� surance Company Name: 14`ab•,..i f l.,ttto ( `(11 f n e..p_ ilicy#or Self-ins.Lic.#: I' a I •A �^ Expiration Date: (—I � o1019 b Site Address: 3 men kr.•etr-Afh Ad-0� ae341'4 NI City/State/Zip: C5,)14&,7 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 le 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$250.00 a da a ainst the violator. Be advised t .t a copy of this statement may be forwarded to the Office of vestigations the DIA for insurayee\overage veil a on. /o hereby certify un • e ains a n penalties o p•jury that the information provided above is true and correct. atu4:- - — / . • ,. Date: (a)31 ao%i ione#: Sill 35`1. 777$ 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#: