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Home My WebLink AboutBLDE-19-001444 • 4 Commonwealth of Official Use Only IL Massachusetts Permit No. BLDE-19-001444 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked JRev.1/07) 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 ININK OR TYPE ALL INFORMATION) Date:9/11/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pertorm the electrical work described below. Location(Street&Number) 18 LEWIS BAY RD Owner or Tenant COMITE RITA M TRS Telephone No. Owner's Address COMITE CARMEN ANTHONY TRS,24107 CEDAR RAPIDS RD,PUNTA GORDA,FL 33955 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 ❑ No.of Meters - New Service Amps Volts Overhead ❑ Undgrd 0 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- 1:1No.of Emergency Lighting grnd. grnd. Barter,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 - initiatine 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 Signs Ballasts No.of Devices or Eauivalent 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 ❑ 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) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$50.00 � 'o/3/I6tit" 4 /� pq� r 0 icialUseOnly A Commonurea o////aooachusa _ _ t c PennitNo. CCCIII�� l! • e,�Mr-Q ;k c7 �1= Z *Department o�Jiro�ervicei %CV" Occupancy and Fee Checked 4,— ,, BOARD OF FIRE PREVENTION REGULATIONS [Rev 1/07] (leaveblank) • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 Ca 12.00 (PLEASE PRINT IN INK OR 'EALL INFO TIO Date: .0 0 • City or Town of: q mint (i) To the Inspec or of fres: By this application the undersign.. :ves notice of bis or he '.tendon o. •o the electrical work described below. Location(Street&Number) 1 a ass n Owner or Tenant Cn� f-rp p n Po rn i P Telephone No. l 13 ' Owner's Address S AM r Is this permit in conj ction with a building permit? Yes ❑ No 0 (Check Appropriate Box) PurposeoYUuilding .IA)P 1I i �Q Utility Authorization No. Existing Service_ Amps / Volts Overhead 0 Undgrd❑ No.of Meters 60 New Service _ Amps / Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity � i�� ... Location and Nature of Proposed Electrical Work: �a:ni �1`•e� �. — Ai Al • .--' Completion of the following table may be waived by the fnssèctOr 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 No.of Luminaires Swimming Batte Units Pool Aboved. ❑ In-m 1. ❑ No.ofEmergency Lighting n 2 No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number-'Cons_•,.KW — No.of Self-Contained P Totals: Detection/Alerting Devices Municipal Ohm No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ No.of Dryers HeatingAppliances KW security Systems:* ry PP No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Si• s Ballasts No.of Devices or E.uivalent ^ No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent g OTHER: e ecommunications T irmg. Attach additional detail{Neared,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) l Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. 6° INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless l! 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 temp,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAM : C it) NSLon •G to 4- A: '"I.1 - 'r ' LIC.NO.: ` K f % LIC.NO.:on/S� • Licensee:` t M the ice eln Signature Il Bus.Tel.No.• 25Ln X215 Addreseable,era$ _exern tom"to license n ber line.) t 0 k Alt.Tel.No.:�� Address: 7i ✓L`L.fj7'�JOIU �iti�� iJIC :t Ott int *Per M.O.L.c.147,s.57-61,security wor requires Department of Public Safety"S"License: Lk.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally fequired by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner 0 owner's lent Owner/Agent I PERMIT FEE;$ 5O.1j° Signature Telephone No. (� • 4) r tt - • The Commonwealth ofMassachuseits l _''M�= t l Department ofIndustrtalAccidents i`� 1 Congress Street,Suite 100 ' Boston,MA 02114-2017 �"2� www.massgov/dia Workers'Compensation Insurance Affidavit:General Businesses.. TO BE FILED WITH THE PERMITTING AUTHORITY. A. .'leant Information Please Print Le!ibl Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO.,INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664. phone#:508394.7778 Are you an employer?Check the appropriate box: Business Type(required): 1.p I am a employer with 10. _employees(full and/ 5. 0 Retail or part-time).* • • 2.0 I am a sole proprietor or partnership and have no 6. QRestaurant/Baz/Eatu gEstablishment 7• Q Office and/or Sales(incl.real estate,auto,etc.) employees working forme in any capacity. 3.Q [No workers'comp.insurance required] 8. 0 Non-profit We are a corporation and its officers have exercised 9. 0 Entertainment • their right of exemption per c.152,§1(4),and we have 10.0 Manufacturing 4.Qno employees.[No workers'comp,insurance required]** We are a non-profit organization,staffed by volunteers, I1.❑Health Care with no employees.[No workers'comp,insurance req.] 12.0 Other *Any applicant that checks box 81 must also fill out the section below showing their workers'compensation policy intoimation. **If the corporate officers have exempted themselves,but the corporation has other policyurequired and such an organization should check box WI. am an employer that Is providing workers compensation insurance for n:y employees. Below Is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address:23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL,MA 02467 Policy#or Self-ins.Lie.#1821AExpiration f Attach a copy of the workers'compensation policy declaration page(showing the policy nu berOmoeand expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine 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 of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification.. Ido hereby cerci :.• ,, 'endues o perjury that the information provided above is true and correct Si: afore: ` ' " 1 sate: - ' one;•508.394-7778 Official use only. Do not write In this area,to be completed by city or town official City or Town: IssuingAuthori Permit/license# ty(circle one): • 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia