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HomeMy WebLinkAboutBLDE-19-000796 o� l AIN or Commonwealth of OffcialUse Only Massachusetts Permit No. BLDE-19-000796 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 WINK OR TYPE ALL INFORMATION) Date:8/9/2018 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. d.]f18 r 3a-7- ©Q 87 Location(Street&Number) 20 BOXWOOD CIR VILLAGE J✓`�v l� f ` / Owner or Tenant BRINCKERHOFF GILBERT D TRS Telephone No. Owner's Address BRINCKERHOFF SUSAN S,20 BOXWOOD CIR,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 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: HVAC replacement. Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of CeiLSusp.(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 No.of Zones No.of Switches No.of Gas Burners 1 No.of Detection and initiating Devices No.of Ranges No.of Air Cond. 1 Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number I Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local 0 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 Siens 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 CIR,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 t9A_ fzidie et, ea cto 6IIB eti Commonwealth.o/rr/adsacAudelld 0 tem se n y r,t (/ Permit No. QQ —079 i_151x. ccyy� cc77 (� fit_ Thepartment of ira Serviced a �5 Occupancy and Fee Checked . `+,z „ 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 ORI'VE ALL INFORMATION) Date: CUA 16/1 q City or Town of: 1 f{(11t1(J u I To the Inspector of Wires: By this application the undersigned give notice of is or er intention to perform the electrical work described below. Location(Street&Number) , `jt�0 , is t, t I if r d" : l ',. . 5 Owner or Tenant Rrinicer off Telephone No.S 0$3 al Cl . Owner's Address Saint �/ Is this permit in conjunction with a building permit? Yes ❑ No E 1 (Check Appropriate Box) Purpose of Building ll Willi yt[i Utility Authorization No. Existing Service Amps J / Volts Overhead❑ 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: y711 4 4 jV / 1 I 1.4 A. I A la , Completion of the following table may be waived by the Inspector of Wires. otal No.of Recessed Luminaires No.of Ceil:Sus . Paddle Fans No.of TVA P (Paddle) Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.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 moo.InDet v Initiatinnggon Devic ces No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump _Number l Tons [KW No.of Self-Contained Totals:I I I i Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local 0 Munnniceicptiaoln ❑ Other No.of Dryers Heating Appliances KW Security Systems:" No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total IIP 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 e BOND 0 OTHER 0 (Specify:) ^, I certify,under the pains and penalties of perjury,that the information on this application is true and complete. (--4 t,P FIRMNA F (t) 10 LAW ' ., • b g - •r • LIC.NO.: `7316— (J 1 Licensee: jC4 M.° I'll 2LV JN • Signature 7 r 1 LIC.NO.:o918.n. SO c.( ips (If applicable,ent "exern t"in the I cense nu rber line.) Vj Bus.Tel.No.•Sr38 3 911.777r5 e• l`�� fl Address: 1 Ager-POPPGt1r-a ,Vittfl yt9-�MouTt-Lmi 07.66 Alt.Tel.No.: 4P V v *Per M.G.L.c.147,s.57-61,security wort(requires Department of Public Safety"5"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally cr 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 PERMIT FEE:$ Signature Telephone No. L Owlanai/inns Ir444/II J aI, oosina.MJ4s.J o a4.....\ Department of Industrial Accidents i =_;'lids- t Office of Investigations _Ei�L 600 Washington Street Boston,MA 02111 t�`��� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name(Business/Or//ganization/Individual): E'F•IN:edI0v;, elthAt i g' �.e0A, Qs.,.f alt, Address: '' KPoe&w, " " „ -• . Cira� City/State/Zip: So,i yon-,,,,k, HA. ` Phone#: `Db-39'1-1'171 Are you an employer?Check the appropriate box: Type of project(required). XI am a employer with 20 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors .❑ I am a sole proprietor or partner- listed on the attached sheet.= 7. 0 Remodeling ship and have no employee§ ; 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 .❑ 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 boz NI must also fill out the section below showing their workers'compensation policy information. -homeowners 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. am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. /n� � surance Company Name: P-fY tm.,a r1 u 1-tle.2 (f�f v Co, vty )licy#or Self-ins.Lic.#: r3 a I Pr • Expiration Date: (—] — ail tI .b Site Address:t)3 Gowcen.rbeJb,, A,1.21 CPeLknJ4• IAA City/State/Zip: eayt,7 ttach a copy of the workers'compensation policy declaration page(Thawing the policy number and expiration date). allure 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$250.00 a da a ainst the violator. Be advised ta.t a copy of this statement may be forwarded to the Office of vestigations the DIA for insura• - overage veri a'on. lo herebyC( certify um e e ains a penalties o p•jury that the information provided above is true and correct. - atur / Date: la i aOt- tone#: .Ug; t'i r 777$ . Official use only. Do not write in this area,to be completed by city or town official v City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: