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Home My WebLink AboutBLDE-19-001275 1 a. Commonwealth of Official Use Only Massachusetts Permit No. BLDE-19-001275 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:8/30/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pertorne etec cal work d cri ed below. w , Location(Street&Number) 30 WINDEMERE RD 1'l A tlJ. 7 ElE�l v Owner or Tenant CHAGNON KIMBERLY E tilt Telephone No. Owner's Address 81 CAPT NICKERSON RD,SOUTH YARMOUTH,MA 02664 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 ❑ 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 0 In- ❑ No.of Emergency Lighting grnd. rnd. 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 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 ❑ BOND ❑ OTHER El (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 LTC.NO.: 21829 Of 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) El owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$50.00 t,___Et cy cc7� CC�r Permit No. /� a T eparlmenl o/.71ra. e#viced " Z�y r- • Occupancy and Fee Checke • e> BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] peaveblank) •1 . APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cod yy C±527 527CMR 12.00 , (PLEASE PRINTININK ORT9EALL IN ORMATION) Date: City or Town of: • 0114 Q1+IA To the Inspector of Wires: By this application the undersigned gives notice of is or her intent!.a t•perform the electri'al work describ d below. Location(Street&Nuumber) A 'A ' '// ' /r 1 0 t � • Owner or Tenant Rut)ut) jaQ 1 A//( Telephone No.5191232_0111 i Owhei'sAddress (Ain / Is this permit inconjun tionwit a building permit? Yes ❑ No [� (Check Appropriate Box) Purpose of Building VJ'Q�1f n'1 Utility Authorization No. Existing Service_ Amps Volts Overhead❑ Undgrd❑ No.of Meters New Service _ Amps / Volts Overhead❑ Undgrd❑ No.of Meter's Number of Feeders and Ampacity ,C cat✓ . Location and Nature of Proposed Electrical Work: C.leaf l c 1/J0 ,�-e f r',` . . .1 n5-}A1 1 Com'teflon o the ollowin:table m be waived b the Ins'ectora Wires. No.o Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers INA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.of Emergency Lighting No.of Luminaires Swimming Pool grnd. grnd. 0 Battery Units 1.- No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS. No.of Zones No.offetection aria No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Tony No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons ICW No.of Self-Container _ Totals: _ Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW Local❑ Connection 0 Other Appliances KW TecurityS stems:" Heating No.of Dryers pPNo.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 0 undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Vikr BOND 0 OTHER 0 (Specify:) I certify,under die pains and penalties of perjury,that the information on this application is true and complete. r'-4— FIRM NA C tO VSlout • _ mfr. 1 e r' . r • LIC.NO.: ?IC- ‘....o lL Ln '�N Licensee:g{C n's° Signature " / A LIC.NO.:a18 (""' V (If applicable,em- "exem'C in the 'cense number line) 4 Bus.Tel.No.• d8 Address: ; :/LiON . u ;aCla• t'� i D 66 Alt.Tel.No.: Cg:' cf. =1? *Per M.G.L.c.147,s.57-61,security wor requires Department of Public Safety"5"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally T 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 I PERMIT FEE: 5 Signature . Telephone No. . JdiG l Sia - a SSC. a.vrrwravrsrrcrasara J+rs.wrumarsra.aarr l = Department of Industrial Accidents y_'dill=611 S P Bie111�_ � Office of Investigations 2t Wll`-_ 600 Washington Street _c,Y Boston,MA 02111 wwwanassgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers licant Information Please Print Le.ibl 'ame(Business/Organization/Individual): E.1-.Wtvtslpw CAtiW g 0. a O. (1C r ddress: ; : .odor) '. t e, i icy/State/Zip: o,s v•-o.., Phone#: 5i8-39` _fl' 9 e you an employer?Check the appropriate box: VI am a employer with 70 4. 0 I am a general contractor and I Type of project(required): • 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.= 7. ❑Remodel ng ship and have no employees These sub-contractors have working for me in any capacity. workers'comp.insurance. 8. 9 D on [No workers'comp.insurance 5. 0 We are a corporation and its 9. Building❑ addition ] 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. insurance re uired, t C. 152,§1(4),and we have no 12.0 Roof repairs q ] employees.[No workers' comp,insurance required.] 13.9 Other applicant that checks box til must also fill out the section below showing their workers'compensation policy information. • • teowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. rectors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site motion. miceCompanyName: au ow.) Mo e-- '� (_t oat 0uiS''1 y#orSelfins.Lies.#: $ Pc� al Expiration Date: (-1 -• a019 ;ire Address: Lies...#:___________ CI t s sl„ . "tl City/State/Zip: 0a467 eh a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). re to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ip 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 to$250.00 a da a:ainst the violator. Be advised •t a copy of this statement may be forwarded to the Office of tigations • the DIA for insura. . overage veri a on. iereby certify an , - penalties or• u �j ry that the information provided above is true and correct. � ' Date: ( . i 101' e#: 1 - 777: • -ficial use only. Do not write in this area,to be completed by city,or town official • • 'ty or Town: Permit/License#uin Authority(circle one): Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Other ' ntact Person: Phone#: 1