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HomeMy WebLinkAboutBLDE-19-000929 i ._ a� Commonwealth of Official Use Only ,fg\ Massachusetts PemvtNo. BLDE-19-000929 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 IN INK OR TYPE ALL INFORMATION) Date:8/16/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perlorm the electrical work described below. Location(Street&Number) 15 MOCKINGBIRD LN . (� Owner or Tenant AVITABILE ANTHONY A Telephone No. v , Owner's Address AVITABILE M JUDITH, 15 MOCKINGBIRD LN,WEST YARMOUTH,MA 02673ti 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: Install generator. 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 `?r'1') No.of Luminaire Outlets No.of Hot Tubs Generators 1 KVA No.of Luminaires Swimming Pool Above CIlo- CINo.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 No.of Detection and Initiating Devices No.of Ranges I No.of Air Cond. Total No.of Alerting Devices l 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 Enulvalent 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: V(p/' Attach additional detail if desired,oras required by the Inspector of Wires. N 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"in the license number line.) Bus.Tel.No.: Address:8 REARDON CIR,S YARMOUTH MA 026641207 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 CiA I kt.2IT 8/z24f3 t 7// 71/8 t )' � ,�ommanwea..L..of ..,aaeac,acdettd 1 —4gy. Ltf icyC� Permit No. ECR'©°I 7,4 t - TheP artment°I giro Serviced C 4 p1 £ b BOARD OF FIRE PREVENTION REGULATIONS [Rev.Occupancy blank)ni, „� 1/07] (leave APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527CMR 12.00 (PLEASE PRINT IN INK OR TY(PF ALL INF�II rOrR�MATION) Date: % / I 2, / ( 5 City or Town of: 1 t&(tv�(V`fit To the Inspector of Wires: By this application the undersigned gives notice of his or er int ntiqn to perfo the electrical work described below. Location(Street&Number) 1C) Mb(<)i4U d Ltori I aft/0I)41 02613 ' II ' Owner or Tenant P'vItkov (l KOab�lt Telephone No. 50539say49 Owner's Address Cjti i'll.eJ Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building b we Ili n CI Utility Authorization No. Existing Service_ Amps J / Volts Overhead❑ Undgrd❑ No.of Meters • New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: c cYLProom 1(\c3-c --0-401/1 011011 Camdetion o the ollowin: table nr be waived b the Ins.ector a Wires. otal No.of Recessed Luminaires No.of Ceil:Sus . Paddle Fans No.of TVA P (Paddle) Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimmin Pool Above ❑ In- ❑ No.ofEmergency Lighting g grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS [No.of Zones in and No.of Switches No.of Gas Burners No.of DetectInitiaating g Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat!ump Number Tons KW_ __ No.of Self-Contained Totals: " .. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW -SecNro.tof Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: • Attach additional detail((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. Cr— ,t CHECK ONE: INSURANCE BOND 0 OTHER 0 (Specify:) �-P I certify,under the pains and penalties of perjury,that the information on this application is true and complete. r"--) C�1 FIRM NA Kr of105Low PL.VAI pip 6- fits �/}� •� t1U' LIC.NO.: `31C.— (----- i �—" l '' —�{^— LicenseeiK,Vm(Ln /V`LLV 10 Signature // � LIC.NO.:9/S/`Z`1 i i (If applicable,ent° "exem.t"in the I'cense nu ber line.) t/ Bus.Tel.No..508.3 914.716 0 Address: : Ja'L CA) U, is ;fit/i e O 6� Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security wor requires Department of Public Safety"S"License: Lie.No. 1 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 ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. f II4 VV$$$$$$1.90M91.1.6111.••V'£IsNJJIf4Iff0.ILfeJ *AM ,= DepartmentofIndustrial Accidents _,' � t Office of Investigations atri6600 Washington Street Boston,MA 02111 J-7441- -f www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information c Please Print Legibly Name(Business/Organization/Individual): EI�:WtnSi0 OlUI+.I7wtct g Vita\,✓) Qe.} int, Address: tch, ' Q.en Cirrl� hive City/State/Zip: Soon IonsAwkn Hf- Phone#: 501- 399-177S? Are you an employer?Check the appropriate box: Type of project(required): XI am a employer with '70 4. 0 I am a general contractor and I 6. ❑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.> 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 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 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.9 Roof repairs insurance required.]T employees.[No workers' 13.❑Other comp.insurance required.] my applicant that checks boz III must also fill out the section below showing their workers'compensation policy information. • -lomeowners 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. sm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. Aro, _) I surance Company Name: hr ro,..1 r-kok A i._./1 f n Ca, ,ny )licy#or Self-ins.Lie.#: 18 a I •4 !"' '1 Expiration Date: I—[ — 101q I ib Site Address:.23 �c✓l wee-141- Al C4Rg I�,1% City/State/Zip: 004 67 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 ti a copy of this statement may be forwarded to the Office of vestigations the DIAfor insurar . overage veil a,on. lo hereby certify un e ains a r penalties o p•jury that the information provided above is true and correct. gnat& • , , Date: la)3 iaf)17� cone#: .51)%:31h1- 797 ' 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#: