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Home My WebLink AboutBLDE-19-001102 y• or Commonwealth of Official Use Only arLIA Massachusetts Permit No. BLDE-19-001102 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:8/22/2018 City or Town of: YARMOUTH To the Inspector of Wirer By this application the undersigned gives notice of his or her intention to perlorm the electrical work described below. Location(Street&Number) 95 ELDRIDGE RD Owner or Tenant HUSZAR MARGARET I TR Telephone No. Owner's Address MARGARET I HUSZAR LVG TRUST,95 ELDRIDGE RD,SOUTH YARMOUTH,MA 02664 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 El 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 boiler 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- InNo.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 Space/Area Heating KW Local 0 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 I 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 ❑ (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 CR,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 deg ?hut 8 �� __ .,ommonwea.,.,of .;,adlac.-udeild 1 I ( (0 2- �' Et c� c7 n Permit No. l i ' E i 5 1Jepartn net of ire Service! Occupancy and Fee Checked 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(MEC),527 CMR 12 00 (PLEASE PRINT IN INK OR TITIE ALL INFORMATION) Date: € 1 70 / 1 City or Town of: rn1oil 1-tn To the Inspector of Wires: By this application the undersign. grvesye'ce .f his .r her inte 'on to pe for . the e -ctrical work describe. .elow. Location(Street&Number) £ I 4 / ik /f / A a / I CYO Owner or Tenant Mehr G re Ru c zap Telephone No.S039411% Owner's Address CO pw e Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building DwtIJsetO/f Utility Authorization No. Existing Service_ Amps J I Volts Overhead❑ Undgrd❑ No.of Meters New Service _ Amps / Volts Overhead 0 Undgrd❑ No.of Meter's Number of Feeders and Ampacity 7- } Location and Nature of Proposed Electrical Work: 4a S 7701 f( 1454 Completion of the following table may be waived by the Inspector of Wires. No.of 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- N.J.of Emergency Lighting • No.of Luminaires Swimming Pool 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.IInitiaattinnit gon and ng Devices Total No.of AlertingDevices No.of Ranges No.of Air Cond. Tons No.of Waste Disposers Bleat Pump Number�lions KW_ No.of SelfContained p Totals: I .. Detection/Alerting Devices paOther No.of Dishwashers Space/Area Heating KW Local❑ Connection l ❑ No.of Dryers Heating Appliances KW -Security Devices Y No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.IIydromassage 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 coveragetis in force,and has exhibited proof of same to the permit issuing office. p� 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. J" \D FIRM NA1V : c 11) o5LOW • ..td' • a" res r , 'r . LIC.NO.: `31 L ---- Licensee: ( (L/) Alla111) Signature ' r ' LIC.NO.a16 I`r-1 (Ifapplicable,eta "exem it"in the 'cense nu 'her line) 4W. Bus.Tel.No.•5-a8.3941.'7?7e _ ep LJ� Address: - i/L✓ON U- la :sr/d r ` 0 6/ Alt.Tel.No.: 1/4.2T O Per M.G.L.c.147,s.57-61,security wor requires Department of Public Safety"S"License: Lic.No. err_ U 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. • '�\ , a M. '.w.a.w..rrlimn J uawuumt,swuasw Department ofIndustrial Accidents r ' ' ,=.�t Office of Investigations MITE 600 Washington Street Boston,MA 02111 •-1/4. ,'" www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E.F.Wty-lova Qlo...6I L �' ^ 4me+� ♦e� lilts Address: ¶' Qeodtx1 Ca�Q_' Q • City/State/Zip: Sash 5CYW,e,, in t4Pc Phone#: G8-39`1-717V . .re you an employer?Check the appropriate box: NrI ant a employer with '70 4. 0 I am a general contractor and I Type Newf projectn (required): ); employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction ❑ I am a sole proprietor or partner- listed on the attached sheet._ 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. [No workers'comp. 9. ❑Build ng addition insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.9 Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.9 Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other y applicant that decks box#1 must also fill out the section below showing their workers'compensation policy information, uneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. man employer that is providing workers'compensation insurance for my employees. Below Ls the policy and job site 'motion. urance Company Name: f fyp,.,y i` •Ave-4Th f n c.p_ Cana-0i icy#or Self-ins.Lic.#: 1$a I A 9 Expiration Date: (�-[ - acm Site Address:a3 Ennr.xvw,.eu-,l{ql A-Q/ Ca y{. NI City/State/Zip: Oa4 67 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 ip 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 insure overage veri a,on. t hereby certify um e ains a penalties o p•jury that the information provided above is true and correct oatuT • / . . Date: ]a)31 )a011' ne#: Stja:3l`i• 797' — _ -- — 7fficial use only. Do not write in this area,to be completed by city or town official . • :ity or Town: Permit/License# ssuing Authority(circle one): • ..Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector i.Other 3ontact Person: Phone#: J