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Home My WebLink AboutBLDE-19-001605 1 ..---- * /� Of Use Only ,�. Commonwealth of Massachusetts Permit No. BLDE-19-001605 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked JRev.l/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:9/17/2018 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) 315 UNION ST Owner or Tenant CLIFFORD HELEN Telephone No. Owner's Address CLIFFORD MARY JANE,315 UNION ST,SOUTH YARMOUTH,MA 02664-4563 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 Undgrd ❑ 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: Wiring for indirect 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- CINo.of Emergency Lighting grnd, grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS 1No.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 ❑ 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 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 DR,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 „ `.. cy c7 �a PermtNo.—��cc 71 -a Thepartntent o/.}ire&Mced mil- —1•t�C5 L , 1 —• �w v! Occupancy and Fee Checked \cat BOARD OF FIRE PREVENTION REGULATIONS [Rev 1/071 peaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with theMassachusetts Electrical Code�M/EC,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: q j II I City or Town of: \/arm o u41n 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) IS on 4-. S 'I C a Owner or Tenant 442-11221 GI{cord Telephone No.,c ..574 869. Owner's Address ►t.n .. S. &P is • (' MIA- ” .6q_ Is this permit in conjunction with a building permit? Yes El No g---- (CheckAppropriate Box) Purpose of Building btut1tii 5 Utility Authorization No. Existing Service_ Amps / Volts Overhead 0 Undgrd❑ No.of Meters __ New Service _ Amps / Volts Overhead❑ Undgrd❑ No.of Meter's _— Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: sv�It( + Ins%a11 Inawett hot- t►.>• 2r hoA{er . n� Com.letion o the ollowin:table in be waived b the Ins actor o Wires. Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.ou}mergency Lighting No.of Luminaires Swimming Pool grad ❑ grad ❑ BatteryUnits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS. No.of Zones a No.ofbetection and No.of Switches No.of Gas Burners Initiating Devices 6,., No.of Ranges No.of Air Cond. TotalnNo.of Alerting Devices T No.of Waste Disposers Heat Pump Number Tons....KW No.of Self-Contained Totals: ~ Detection/AlertingDevices Local❑ Municipal Other No.of Dishwashers Space/Area Heating KW Connection ❑ tems:" No.of Dryers evices or Equivalent No.of Water jimur±s_____co. g: Q Heaters evices or Equivalent 60 No.Hydromassage Bathtue iceso rs Wiringg: evices or E uivalent OTHER: Oo Estimated Value of Electrical Work Attach additional detail if desired or as required by the Inspector of Wires. (When required by municipal policy.) //�� • Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. t-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 coverage�,{ is in force,and has exhibited proof of same to the permit issuing office. FJ CHECK ONE:,INSURANCE BOND 0 OTHER 0 (Specify:) I certify,under the pains and penalties of perjury,that the in ormatton on this application is true and complete. . FIRM NA C U) �t 10W • _up • o. ,j•, r' ' r LIC.NO.:n_ Licensee: I Th2.O /•t tV111) Signature r � LW.NO.'918/�`�'I (If applicable,eat "e. m-t"in the 'cense nwiberline.) j Bus.Tel.No.:{d$•39±1'9 ' Address: ; Ilia/011) U. V ire h r t� ' D �6 Alt.Tel.No,: *Per M.G.L.c.147,s.57-61,security wor requires Department of Public Safety"S"License: LM.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/Agent I PERMIT FEE: $ Signature . Telephone No. I — 1 Department of Industria[Accidents bl_ • Office of Investigations l l 600 Washington Street "NY Boston,MA 02111 , nnovanass Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers licant Information "� Please Print Le•ibl arae(Business/Organization/Individual): E.c.Wins* OW Qlu�,b'. g a1 . rae. tet. ddress: : ;-a>;lt+v1 `t Q.. / t ity/State/Zip: au _(,i„ Phone ii:_ 5)8-399.1 e you an employer?Check the appropriate box: I am a employer with 'JO it Type of project(required): employees(full and/or part-time).* ❑haave hired the b sub-contractorscntl contractor r 6. 0 New construction ] I am a sole proprietor or partner- listed on the attached sheettees These t 1• ship and have no employees ❑Remodeling P Y sub-contractors have working for me in any capacity. workers'comp. insurance. $' ❑Demolition [No workers'comp.insurance 5. 0 We are a corporation and its 1 ❑Build ng addition required.] officers have exercised their 10.❑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, insurance required.]T [r and ese kers' no 12.0 Roof repairs employees.[No workers' comp.insurance required.] 13.0 Other applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • leowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ractors that check this box must attached an additional sheet showing the name of the sub-contractors 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. ante Company Name: jlyg ..-s MU11.10.1 l_g (MlA lin • y#or Self-ins.Lic.#: $oZI Pr �` Expiration Date: i—( — ao19 lite Address LENr•Anspvl kfbeal r. ], lilt . NI City/State/Zip: Ca 14 to7 zh 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 tp to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fee to$250.00 a da a:ainst the violator. Be advised t .t a copy of this statement may be forwarded to the Office of tigations • the DIA for insura r - overage veri a on. __________________ rereby certify um• e gins a penalties o'jury that the information provided above is true and correct. tttlrrVII . a. Date: ( . i ao(' #: 1 • 797; falai use only. Do not write in this area,to be completed by airy•or town official •or Town: _________--- i__ -- — uing Authority(circle one): Permit/License# oard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector they tact Person: • Phone#: I