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Home My WebLink AboutBLDE-18-007314 -'A' I Commonwealth of Official Use Only fE�. 11 Massachusetts Permit No. BLDE-18-007314 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked LRev.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:6/26/2018 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) 10 BELVEDERE TERR K. Owner or Tenant JOHNSON BARBARA K Telephone No. \ ' Owner's Address C/O BETSY JOHNSON,22 HAVANA ST,ROSLINDALE, MA 02131 �l 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 El 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: Remodel kitchen&bath room. 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 i Transformers KVA No.of Luminaire Outlets . No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In ❑ - No.of Emergency Lighting grin! grnd. CINo. Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.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 ❑ OTHER 0 (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: DOUGLAS S VELIE Licensee: Douglas S Velie Signature LIC.NO.: 21245 (If applicable,enter"exempt"in the license number line.) Bus.TeL No.: Address:6 SANDY MEADOW WAY,EASTHAM MA 026426104 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 ❑ owner's agent. , Owner/Agent Signature Telephone No. PERMIT FEE:$7100 VQ°66( (trteratfa I 15111,144) Q171(5 Ce) c nt- Q/z,/,''S I S.) 14 Comnwnwealth 01/r/aeesaie.tte Oficiel jse Only . • ' 't c7� �a Permit No. LitJ� 9 ri-vi°g: apartment of Jive Jirnteu S i j{— '' Oavpancy and Fee Checked f7 BOARD OF FIRE PREVENTION REGULATIONS .1/07j (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK -AO MI work to be performed in accendmee with the Massachusetts Electrical Code C) 527 CMA 12.00 (PLEASE PRINT IN INK OR TYP INFORMATION) Date: 212b/MS City or Town of: kt-�'1Ou n'r To the Inspect of Wires: By this application the undersigned es notice of✓his or her intention to perform the electrical work described below. Location(Street&Nu her) I0 0YiV42 eE 1 C�2aie Owner or Tenant Ot{ p(-till � Telephone No. Owner's Address 1(9 Cga.%.1 Peg- �G/t�s—ke�e- 1 Is this permit in conjunction with a building permit? Yes [Or No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service'tte _ Amps / Volts Overhead 0 Undgrd 0 No.of Meter _ t—= New Service _ Amps / Volts Overhead 0 Undgrd 0 No.of Meters _ 7 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (/ -14-4•64(6 tient1,6{x(f)� ( '• Completion ofthe follow ,table may be waived by the Inspector of Wins. No.of Recessed Luminaires No.of Cel.-Snap.(Paddle)Fans Transsformers TKVA V No.of Luminaire Outlets No.of Hot Tubs Generators KVA to ^d; No.of Luminaires swimmingPow Above 0 Io- ❑ No. er Unitsency Lighting gird, grad. Battery Unita No.of Receptacle Outlets No.of OH Burners FIRE ALARMS No.of Zones tand No.of Switches No.of Gas Burners Na InDeteInitiatingInitiatingntion a Devices o Ill No.of Ranges No.of Mr Cond. Toonsl No.of Alerting Devices sen lint Pump Number. Tons KW No.of Self-Contained No.of Waste dap° Totals: 1 Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local0 Mvvttipal O Other Cyonnectloa No.of Dryers Heating Appliances KW Na 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((desired or as required by the Spector 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. i — '' INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless I o r the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The a Q undersigned certifies that such con ge is in force,and has exhibited proof of same to the permit issuing office. CO 1 CHECK ONE: INSURANCEIV BOND 0 OTHER 0 (Specify:) cNi ,;1/4,437, I certify,under the,,Ins and pe ,Ides ..•, at tli Information on this application Is true and complete. i FIRM N / is I a/. • ( 1 ' LIC.NO.: 2 j Z-1-(5-A —_, i RI Licensee: t ♦t.) ABM1 • ,ature A _t _;�yrArt ' LIC.NO.: 5 SO 5 (Ifapplicabl ter"sgempt'In thylicense numbed a) Y Bus. eL No: 0 r - (37/ m Address: / "Ms_trt‘ MFFRW vLM WWt ($51-4414 D 11-2-- Alt.TeLNo. : *Per M.G.L.c. 147,s.57-6f,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner 0 owner's agent. Owner/AgentPERMIT FEE:$ 75- Signature Telephone No. ,per 1 The Commonwealth ofMassachusetts s •avior—Twirl Department ofIndustrial Accidents acini= `d 1 Congress Street, Suite 100 % _ r Boston,MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Businesp/Organiizza'tion/Individual): A e{akn t&L 6'64',eMI s1 fC Address: (2 $Ckitn(Q ve o0-7 City/State/Zip: di , G Q e, I 2 Phone#: 5 g S — 3 Are you u employer?Cheek the appropriate box: Type of project(required): is tam a employer with I' employees(full and/or pati time).• 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in g. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3. I em a homeowner doingall work 9. ❑Demolition ❑ myself[No workers'comp.insurance required)t 4. I nm a homeowner and will be 10 0 Building addition • ❑ hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 1 am a general contactor end I have hired the subcontractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance3 13.D Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,11(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing as work and then hire outside contractors must submit a new affidavit indicating such. :Cottonton that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and job site information. Insurance Company Name: 41 h•M 5ste ecn Ause7pc Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine 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 of up to$250.00 a day against the violator. Ail of this statement may be forwarded to the Office of Investigations of the DIA for insurance - coverage verification. I do hereby certify und.y j ,�jury that the information provided above is true and correct ' f. Si• attire: a sate: P one#: ► `► 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#: