The URL can be used to link to this page

Home My WebLink AboutBLDE-19-000995 a. Commonwealth of Official Use Only ISM Massachusetts Permit No. BLDE-19-000995 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked (Rev.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:8/20/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pertonn the electrical work described below. Location(Street&Number) 11 HAWKS WING RD Owner or Tenant PESSIN GERALD Telephone No. Owner's Address PESSIN SHEILA R, 11 HAWKS WING RD,YARMOUTH PORT,MA 02675 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 ❑ 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 ❑ In- ❑ 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 Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ 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 Sins 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 ❑ 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.: 21629 (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 ❑ owner's agent. Owner/Agent Signature 1("119 /TelephoneNo. PERMIT FEE:$7100 6-71421S c1-10r- Vfl-2) Cil(-lis onzmonwea _ or - ,aeeac ueslle ( L o?9c- n ft cy cc77 Serviced Permit No. �lJ ' 1 L; Thepartment o/Vire Services Occupancy and Fee Checked eg z BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07 °7t.-,.® ) (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYP$ALL INFORMATION) Date: %) I 1 City or Town of: WAD Ad f1 % To the Inspector of Wires: By this application the undersigned gives notice of his or her intentior top-rfor t e electrical Tworkj� described below. Location(Street&Number) • A II A �� LI (� k A V 'A a t1S Owner or Tenant (,>fro ,, if 551✓% Telephone No. 6O36I911C • IC Owner's Address SGtt t. Is this permit in conjunctim.with puilding permit? Yes ❑ No (Check Appropriate Box) Purpose of Building VW��ht^ Utility Authorization No. Existing Service_ Amps _/J Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meter's Number of Feeders and Ampacity / r rl Location and Nature of Proposed Electrical Work: _ hit'lf C(A\.r( 16 ht l La 7 6l, Com vletion a the ollowin: table in be waived b the Ins Total r o Wires. No.of Recessed Luminaires No.of Ceil.Sus . o.of F (Paddle)Fans KVA Transformers No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.of Emergency Lighting No.of Luminaires Swimming Pool grnd. ❑ grnd. ❑ Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS.INo.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Tanyl No.of Alerting Devices No.of Waste Disposers Heat Pump INumber(Tons .IKW No.of Self-Contained Totals: `� Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection 0 Other -Security Systems:* No.of Dryers Heating Appliances KW No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Sites Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications qu v l No.of Devices or Equivalent OTHER: Attach additional detail ifdesired 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�,tis in force,and has exhibited proof of same to the permit issuing office. sC.l 0 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. M 0 FIRM NA CO Il75LOW „t//I- a E ✓ i LIC.NO.: .316.-- ,--- l C- v� % LIC.NO.0/82? (./1 , Licensee: Kat Wan AlM taro signature �! I N (If applicable,entw"exern tom"in the;lilce�n�se�n�u,Tbei tine.) `A V Bus.Tel.No.:508.3 914'77 16. Oc" Address: '$ /l-ffi7a,(/OIU tiff- tt: Uitti{ ifAiZMoutri,siil4 own-- Alt.Tel.No.: mei— g *Per M.C.L.c.147,s.57-61,security wor requires Departrnent of Public Safety"S"License: Liu,No. h1' 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. 1O`l) 1 • MI.\ - t FOG. VUIINIWI01.4µ6,I0 V, 4ra.a,J16YIO,p,LOOJ 1* — Department of IndustrialAccidents _"=At= OfficeInvestigationst 4 Wil, • ff of _�;`_� 600 Washington Street Boston,MA 02111 ‘1,-;;Tor - www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibly Vame(Business/Organization/Individual : E.1-•W pW //�� ) tr,5 .n. L �<0. :�, chs., l.tt. Address: ' KPodtatl Cata¢� r :ity/State/Zip: So,sk+- Ycro.,c,,, in HA. Phone#: 38-3q`1-1'17 1 . re you an employer?Check the appropriate box: Type of project(required): IVI am a employer with '70 4. 0 I am a general contractor and I 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.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. 9. ❑Build ng addition 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 • y applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • smeowners 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 sub-contractors and their workers'comp.policy information. vi an employer t/rat is providing workers'compensation insurance for my employees. Below is the policy and job site )rmation. /� mance Company Name: flYy'ON,.t rh -t10,I .In f eiCaNyvii icy#or Self-ins.Lic.c.(#: 1301 I A- • Expiration Date: (—[ — x019 Site Address:a3 Connr6tr)weo.1111 Ad-Q) C 44j,. gal City/State/Zip: 0,484 117 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..t a copy of this statement may be forwarded to the Office of estigations the DIAfor insure* - overage veri ••on. 'hereby certify un e aims a penalties o p•jury that the information provided above is true and correct.- -- iota - I, / a Date: 1a13 t law ne#: SW:3119. 777b' 9fficial 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 :ontact Person: Phone#: I .1 t