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BLDE-19-000775 • Commonwealth of Official Use Only AMassachusetts Permit No. BLDE-19-000775 rt" BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked JRev.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:8/8/2018 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) 181 SILVER LEAF LN Owner or Tenant SPURR GARY A Telephone No. Owner's Address 181 SILVER LEAF LN,WEST YARMOUTH, MA 02673 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 No.of Luminaire Outlets No.of Hot Tubs Generators 1 KVA No.of Luminaires Swimming Pool Above I, ❑ - ❑ No.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 No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump __ Numher 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 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,secunty 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:$50.00 1 4 9/r7/f8 , O ,�tt,, q�qfficial Use Only Commonwealth o�///aeeae�ueetE� f ccyy cc-�� (� Permit No. �q en C. c M nim^: 1Jepartment al.}ire Serviced •{ s-I- •` Occupancy and Fee Checked t"•,. - BOARD OF FIRE PREVENTION REGULATIONS [Rev.-,:,.,, (R 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR12.00 (PLEASE PRINT WINKORT P ALL INFORMATION) Date: co l 61 1 fJ City or Town of: r Ofrh,0(,,4141 To the Inspector of Wires: •. By this application the undersig ied gives notice of his pr her intention to perform the elec,ical work described below.lo Location(Street&Number) ` A 51 el 1 ' , L t • 4- fiA 9 � D- • I Owner or Tenant COf X putt Telephone No.5043115 t 17;0 Owner's Address Sate f �/ Is this permit in conjunction with a building permit? Yes ❑ No L// (Check Appropriate Box) Purpose of Building I1/0I);Vi Utility Authorization No. Existing Service_ Amps V Volts Overhead❑ Undgrd❑ No.of Meters New Service _ Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity 1' Location and Nature of Proposed Electrical Work: Gen.foi J*( 9-pi )I Completion of the following table may be waived by the Inspector of Wires. otal No.of Recessed Luminaires No.of Ceil:Sus .(Paddle)Fans No.of TVA P Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires SwimmingPool Above ❑ In. ❑ No.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS. No.of Zones d No.of Switches No.of Gas Burners No.InDaevices Detection Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Irons KW No.ofSelf Contained Totals: � Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local 0 Municipal ❑ Other P Connection _ No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water 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: Inspections to be requested in accordance with MEC Rule 10,and upon completion. ti-% 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 � t coverage, is in force,and has exhibited proof of same to the permit issuing office. UN CHECIC ONE: INSURANCE I BOND 0 OTHER 0 (Specify:) LA J I certify,under r the pains and penalties of perjury,that the information on this application is true and complete. �a-p- •=—.. FIRMNAIVJ:INK'F (O/06COW put„,--- ,,,,t, °" (�'tl•�- ��• Il_ LIC.NO.: `a'1C� t ` Licensee:( C1M(L/) Al€1,111 I Signature LIC.NO.:al82y �O \^_ (Ifapplicable,enter"exempt""in the,/l'cense nu bei line.) I Bus.Tel.No.:ri r�B'3 9`1•'77. - 19 Address: $ /LMI',(/ai (.4 DOH i'i4'tmotCtt4ikW Dy0G Alt.Tel.No.: "Per M.C.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 have the liability insurance coverage normally .(-r- required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner 0 owner's agent. '�C" Owner/Agent Signature Telephone No. PERMIT FEE.'$ • 4 1o1 ' ' M� In.. RUBIS,I6VI6IYL6L40.041.10041.400.11•40.041.10041.400.11•66.140.041.10041.400.11•66.1640.04140.041.10041.400.11•66.1L6I6 VJ VJ04I !{.66 r. ��b Department of Industrial Accidents - ryt= t Office of Investigations _e°lift_ 600 Washington Street =41 = Boston,MA 02111 %Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information c1 Please Print Legibly Name(Business/organization/Individual): L•ctWtr\st0,,.! CAU,M611 L �.co.\-✓ve, Ce., lel( ((60-awlCade— City/State/Zip: i I Address: ' wl _ a (1X City/State/Zip: Sw 'crw.ey.sttn NAS Phone#: `5O&- 399-1t?St Are you an employer?Check the appropriate box: Type of project(required): Ari am a employer with 70 4. ❑ I am a general contractor and I 6. 9 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. 0 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 12.0 Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.0 Other my applicant that checks box#1 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. 'ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. //�� � ` surance Company Name: Arm....) (`1Jtile.A C� )licy#or Self-ins.Lic.^#: 1$oZ I Pt' • '1 Expiration Date: (-1 - a©I9 ib Site Address:.23 hCnMcv)wev-J#k M.t-QI CFeg Y1r7I City/State/Zip: Ca 4 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 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 tI.t a copy of this statement may be forwarded to the Office of vestigations.6 the DIAlfor insura I• overage veru on. lo hereby certify un • I penalties o rury that the information provided above is true and correct. :natuT:: _ — IALL Date: 1-d. 1 aot- lone#: 51)51:35`1. 7778 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 ' ' 1 6.Other Contact Person: • Phone hi: