E-19-1209 Commonwealth of Official Use Only
Massachusetts Permit No. BLDE-19-001209
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:8/28/2018
City or Town of: YARMOUTH To the Inspector of Wires: /_1n e—7 q4--9-'/,n
By this application the undersigned gives notice of his or her intention to perionn the eht,jucyI work described be`l __��`"' to -r
Location(Street&Number) 44 FOREST GATE VILLAGE `lG�/`Q�\vf's
Owner or Tenant LIBMAN LEONARD S TRS Telephone No.
Owner's Address LIBMAN BONNEY W TRS,44 FOREST GATE VILLAGE,YARMOUTH PORT, MA 02675
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 ❑ No.of Meters
New Service Amps Volts Overhead 0 Undgrd ❑ 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- 1:1No.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 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 I 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
t 9A `P/ull'e
Ke-
tab ?4C/veli
_ommonwea _ or ,addac daitl Ot (2 O9'
i� larIt Permit No. _ [—Jll
o .• : T epartment o/Yiro✓orvice3
J -- : 111=; Occupancy and Fee Checked
.2 Asa BOARD OF FIRE PREVENTION REGULATIONS [Rev. (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 0527 CMR12.00
(PLEA SE PRiNT IN INK OR TXPEALL INFORMATION) Date: 2 /
II// 45
City or Town of: voifyytOvh., To the Inspector of Wires:
By this application the undersignec ives notice of hi{or her intention to perform the electrical work described belo .
Location(Street&Nu(m�ber) I t 4- C/ 4-r / . Gl ( i A Of/f /Or2 5Q
Owner or Tenant UP11ii1(A `7 1euit1 Telephone No. $041 y -y 9
Owner's Address 9a 111-€
/ �/
Is this permit in conju ctlon with a building permit? Yes ❑ No L (Check Appropriate Box)
Purpose of Building IJuuA lit/(i Utility Authorization No.
Existing Service_ Amps J / Volts Overhead❑ Undgrd❑ No.of Meters
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New Service _ Amps / Volts Overhead❑ Undgrd❑ No.of Meters _
Number of Feeders and Ampacity ,
Location and Nature of Proposed Electrical Work: 6(AS Fun/Lott P )/1C TG 1 f It I1 an
Coni.'tenon o the ollowin:table nr be waived b the lns.ector a Wires.
No.of Total
No.of Recessed Luminaires No.of CeiLSusp.(Paddle)Fans Transformers KVA
No.of Luminaire Outlets No.of Rot Tubs Generators KVA
Above In- No.ofl,mergency Lighting
No.of Luminaires Swimming Pool grnd. ❑ grnd. 0 Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS.INo.of Zones
No.of Switches No.of Gas Burners leo.of Detection and
Initiatingon Devices
No.of Ranges No.of Air Cond. Tonyl No.of Alerting Devices
Heat-Pump Number Tons , KW No.of Self-Contained
p Totals: Detection/Alerting Devi
No.of Waste Disposers ces
paOther
No.of Dishwashers Space/Area Heating KW Lacal DiConnecMunicitionl ❑
No.of Drers Heating Appliances Key SecNo.ofDeviceurity :°
Y No.of Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KWSigns Ballasts No.of Devices or Equivalent
Telecommunications Wiring:
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.
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 Vi BOND 0 OTHER 0 (Specify:)
I certify,under the pains and penalties ofperjury,that the information on this application is true and complete.
FIRM NA F to NSCOW • -,ie. . s. s E, r ' ' LIC.NO.: l L
Licensee(le-ja a(Lf M taut) Signature / r i LIC.NO.:9/En
ne
(If applicable,entlIi�'vieinvt"in the rrt�cense nu fiber line.) Bus.Tel.No.:5.08.3 R q•'7
CP o� Address: a3 /L2R7�()0P (..4 Gl- gvutt♦ lindtOutdisst!? 07-4.4.1' Alt.Tel.No.:
t`� 'Per M.G.L.c.147,s.57-61,security worn(requires Department of Public Safety"S"License: Lie.No.
r t� r+- OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
. 7' cf' required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner 0 owner's agent.
Cp'3 0 Owner/Agent I PERMIT FEE: $
v Signature Telephone No.
le
• L I64 `/.J.I.IIO.IIerr&µma VJ srsWJM4I0000, .,
_w== Department of Industrial Accidents •
Office of Investigations
Wins
_;.�`__ 600 Washington Street
Boston,
MA 02111
�rY
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Vame(Business/Organization/Individual): E•c.Wtt\5i Q[Ogektii i g t1<0.r`' Cay I(IC
Address: 3 (4 odor) Circle-'
City/State/Zip: SoAin IerrAc,.Aln Npc Phone II: 'fib-399-7171S/
re you an employer?Check the appropriate box:
Type of project(required):
I am a employer with '70 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
ElI am a sole proprietor or partner- listed on the attached sheet t '7. 0 Remodelng
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'comp.insurance.
[No workers'comp.insurance 5. 9. ❑Building addition
❑ 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
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of applicant that checks box Al must also fill out the section below showing their workers'compensation policy information.
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)meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
rt an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
2rmation. /� �
uranceCompanyName: Arra,...) fiolvev l j n: ACS Carnet-vv.)
icy#or Self-ins.Lie..#: 'Is a 1 A • Expiration Date: (-I - oaO9
Site Address:&} Clevvykon.,reo-A ,_ Ad-41 Ct�.9 ,4 NI City/State/Zip: C '4 i 7
ach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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
tp to$250.00 a da a:ainst the violator. Be advised ..t a copy of this statement may be forwarded to the Office of
estigations . the DIA for intra. ' overage yeti a'on.
)hereby certify um- e tins a penalties o jury that the information provided above is true and correct-
__
, Date: (a)31 law
ne#: sunli• 797S
7fffclal use only. Do not write in this area,to be completed by city or town official .
:ity or Town: Permit/License#
issuing Authority(circle one):
..Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
i.Other
:ontact Person:
Phone#:
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