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Home My WebLink AboutBLDE-19-000795 Commonwealth of Official Use Only iLIOM Massachusetts Permit No. BLDE-19-000795 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:8/9/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives no ice o is or cr in en ion o per orm t e e • •lel work descri ow. Location(Street&Number) 15 YANKEE DR Owner or Tenant VANDEWOESTYNE HENDRIK L Telephone No. Owner's Address 15 YANKEE DR,SOUTH YARMOUTH,MA 02664 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 ❑ 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: Replacement furnace 4 e lI Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddie)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators 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 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: Detention/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 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 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:$50.00 65/2j_. Ca/WWBge Commonwealth o1///asoachudetts Official Use Only %,.‘,~ l t& c7 n Permit No. r '• a Theparfnunt°Ain Sento e sr s BOARD OF FIRE PREVENTION REGULATIONS1p/07ryandFee lank)Checked 3 .c. [Rev. ) (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC,527.CW 12.00 (PLEASE PRINT IN INK ORTYPEALL INFORMATION) Date: ra IO l I Cb City or Town of: •%4{/}14 v An To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) .c Q c ;at I -7 t Owner or Tenant SO' Telephone No.SO$ G 94 / 3/5 Owner's Address I i„ k G 1 N . i ./ .J V b a -- • • Is this permit in conjunction with a building permit? Yes [11 No ' (Check Appropriate Box) Purpose otBuilding tJ�-tf n f 9 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: irce/e.teirKe Corn sletion a the oilowin: table ma be waived b the Ins.ector o Wires. otal No.of Recessed Luminaires No.of Ceil:Sus . Paddle Fans o.of KVA P (Paddle) Transformers No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires SwimmingPool .Above ❑ In- 0 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.Init t and Initiaatin ngg Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons [RW __ No.of SelfContained Totals: I - - Detection/Alerting Devices Municipal Other No.of Dishwashers Space/Area Heating KW Local 0 Connection ❑ No.of Dryers Heating Appliances KW �ecNo.ofDy svices No.of Devices or Equivalent . No.of Water No.of No.of Data Wiring: Heaters KW Sips 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 ifdesired or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) 0 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 cundersigned certifies that such coveragea,tis in force,and has exhibited proof of same to the permit issuing office. 0n CHECK ONE: INSURANCE I BOND 0 OTHER 0 (Specify:) v — I certify,under the pains and penalties of perjury,that the information on this application Is true and campleta �C7 FIRM NA : KF (OWSirW pAkel'VIN(a d` 411Q'f /Ly�p j ___L____ LIC.NO.: '31c- is M Licensee:iA(C{}I lfl f�,?IMO Signature f// G LIC.NO.:9i57..nd �0- (If applicable.entg"erupt:in the l{'cetpe�nu,?rber line.) j Bus.Tel.No.•50:'3 9`7'77�C • CJ Address: "5 /LtFY/c-//ON (4 '44; `1)14114 yt4'QMotG7"t4r mit D7-6�v Alt.Tel.No.: �7" M.O.L.*Per c.147,s.57-61,security woritrequires Department of Public Safety"5"License: Lic.No. C 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 Signature Telephone No. PERMIT FEE: $ 1y 19,1 • i~ g a L,.f. �VO>NOV06rr1•LL6r•j p14uuuen organa wib= Department of Industrial Accidents -1 1 _,'IiIII_= t Office of Investigations %Wit=P= 4 600 Washington Street l Boston,MA 02111 •%L . , www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information (� 1; Please( Print Legibly Name(Business/Orgganization/Individual): E•c•Wtr\$iOW Ylvl,3.46wtcl° g Iltci.V `e} I,•t(' Address: W (Qeoduri Cide. a City/State/Zip: So 3 ks'\ ycr— .4, NPc Phone#: 50E-399-In9 • Are you an employer?Check the appropriate box: Type of project(required): 4-.1 am a employer with 70 4. 0 I am a general contractor and I 6. 0 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.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. 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' 13.0 Other comp.insurance required.] hny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • -lomeowners 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. rut an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. /� � surance Company Name: fIr Y0N....3 CA41/02 r n fp_ Cev.".etwi I )licy#or Self-ins.Lic.#: 'I 3 a i A • Expiration Date: (-I - ?019 bSite Address:a3 Gtnnerwlwes-14-11 I Che3AD4 Yl111 City/State/Zip: 0,)4107 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). tilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a le 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 ti.t a copy of this statement may be forwarded to the Office of vestigations the DIA for insurapeE�overage yeti a,on. to hereby certify un,• e airs a Jpenalties o p•jury that the information provided above is true and correct. , gnatu4:- _ — , S Date: I l ?11 a0r1 . tone#: %i Si.1 • Ti Official use only. Do not write in this area,to be completed by city,or town official City or Town: Permit/License# Issuing Authority(circle one): • 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: • Phone#: