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Home My WebLink AboutBLDE-19-000992 Commonwealth of Official Use Only at® Massachusetts Permit No. BLDE-19-000992 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked fRev.l/071 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK An 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 ol his or her intention to pertorm the electrical work described below. Location(Street&Number) 22 CAPT BRAGG RD Owner or Tenant NEWCOMER WAYNE Telephone No. Owner's Address NEWCOMER KATHLEEN,22 CAPT BRAGG 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 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Replacement Furnace 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. grnd. Batters Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners 1 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 ❑ 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 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 Lige), ? (N (/te -- eCth. O m h Oficial Use n y ommonwea o/ t//aaaac uaelfe �7 Q(� I IMN cy c7 nn Permit No. E` [` O \-1 -e1=% .Department o`Jira Seneca i ' - Occupancy and Fee Checked it >,sg.' 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(M C,527 CMR 12.00 (PLEASE PRINT IN INK ORTXPFALL INFORMATION) Date: (-1J / 6 / S City or Town of: Y(hf/11Oil fin To the Inspector of Wires: By this application the undersigned gives notice of his or her in ,tion to perform thereelectrical work desc ibed below. �� Q q Location(Street&Number) 7„' C i 4-G> e 5 Roc, 5 t Owner or Tenant Wohnf. Mtwcowlj Telephone No.SOS39853I59 Owner's Address Jtit cklin( Is this permit in conju etion with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building (kit lkt Y1 n Utility Authorization No. Existing Service_ Amps / Volts Overhead 111 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: G& . 'hi(ft(A Ct Iasi-aI/G#/OM Com.letion o the ollowin•table m be waived b the Ins.ector o Wires. otal No.of Recessed Luminaires No.of Ceil:Sus .(Paddle)Fans °'° VA P Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators IC A No.of Luminaires Swimmin Pool Above ❑ In- 0 No.of Emergency Lighting • g 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.IInnitiaait ttingon and ng Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons RW _ No.of Self-Contained Totals: ''-" "—' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local 0 Municipal Connection ❑ Other y No.of Dryers Heating Appliances KW cNo.oSDsvices No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters K\Y Signs Ballasts No.of Devices or Equivalent Telecommunications Wirmg: 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. O 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. \D CHECK ONE:.INSURANCE Ef BOND ❑ OTHER 0 (Specify:) I certlni,under the pains and penalties of perjury,that the information on this application Is true and complete. CL - FIRMNAII ( U) QSLOW • .,4b els- e e - 'r . LIC.NO.: cl3`IL r Licensee:QiCth%2.. M u -U(v Signature � LIC.NO.:aI 5771 ,.. T (lfapplicable,ent `ezern t' in the l'censenumber line.) j Bus.Tel.No.•5.0839q•'77- I; Address: 1 AtM�OaP011 5otati liniNout>-114, oybG Alt.Tel.No.: *Per M.G.L.c.147,s.57-61,security worlf requires Department of Public Safety"S"License: Lie.No. ^e(' "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 ant the(check one)0 owner 0 owner's agent. Owner/Agent Signature . Telephone No. PERMIT FEE: $ • Sgla 1' _ VVI/fIIIVI/PrL44II,j I.ANJJ44ISW3t ks w== Department of Industrial Accidents I i— t ! 4_-mi_ Office of Investigations t -°°�_ 0 600 Washington Street • MIN= ^ Boston,MA 02111 \ ';-„ www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information //�� Please Print Legibly Name(Business/Organization/Individual): E I�.Wtr5I OW YIU.4.. t✓t[i '1 1 b� L v1tal Qe} Int I Address: ' Qeodty, CiaQ.. City/State/Zip: So„kn Ycrv'c,.Ain t-t f 1r Phone#: `508-39`1-1'17 1 Are you an employer?Check the appropriate box: Type of project(required): X, I 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 .0 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 • required.] officers have exercised their 10.0 Electrical repairs or additions .0 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' 13.❑Other comp.insurance required.] 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. WI an employer that is providing workers'compensation insurance for my employees. Below Ls the policy and job site formation. 1 surance Company Name: AYyp�,J t Lhie.A n iota n (Thew ,ily )licy#or Self-ins.Lic.#: I S a IA- Expiration Date: (—[ - a019 I bSite Address:923 ccvtr c ).,^ea-141 Atte Cher N;11 � City/State/Zip: Dir-1107 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 re 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 t1.t a copy of this statement may be forwarded to the Office of vestigations the DIA for insura• ' overage veri a,on. to hereby certify un - e ams a penalties o p'jury that the information provided above is true and correct. _not& _ / , , �S Date: ( 1 a . lone#: .51)i:114 e 777g Official use only. Do not write h:this area,lobe completed by city,or town officlaL . • 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#: