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Home My WebLink AboutBLDE-19-001993 '' Commonwealth of OffcialUseOnly �E' !�`' Massachusetts Permit No. BLDE-19-001993 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked IRev.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:1013/2018 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 ele' I work deserib w Location(Street&Number) 3 THISTLE CIR UNIT 33A /1G�'S �A -€tel.!5-Kai Owner or Tenant SIMUNDZA SHIRLEY G LIFE EST Telephone No. Owner's Address 3 THISTLE CIR,YARMOUTH PORT,MA 02675-2532 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appropriate Box) j Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 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 furnace Completion of the following table maybe 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- 0 No.of Emergency Lighting grnd. Rrnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners 1 No.of Detection and Initiatine Devices No.of Ranges No.of Mr Cond. Total No.of Alerting Devices Tons No.of Waste Disposers HeatTotals: Pump Number Tons KW No.of vtion/Al ming.edD Totals: Detection(Alcrtin¢Devtces t� 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 ❑ BOND ❑ 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 (Ifapplicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:8 REARDON CIR,S YARMOUTH MA 026641207 Alt.Tel.No.: *Per M.G.G.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 CZ ( (8 Onl /� pp�� qq� I -----_r---- Official Use--. l Corrunonweaitia o�///aJ3achuletfd P-2-9 �Ul �eq �c cy �J ((1� Permit No, • T eparimeni o/giro&ruiced fsF1= ' Occupancy and Fee Checked � _ ,, BOARD OF FIRE PREVENTION REGULATIONS [Rev 1107] (leave blank) • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK • All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 27 12.00 (PLEASE PRINT IN INK OR TYPE AL INFORIVIAT O Date: /O/i // $ City or Town of: 11 A- Mou.M Wier To the Inspector of Wires: By this application the undersigned gives notice of his or her mtentionfo perform the electrical work described below. L'o'cation(Street&Number) .3 15172-0 at • /$ Owner or Tenant aS ,4 _ •JLp/UZf 4.S&./ Telephone No. 6'4 I Og Owner's Address f9 1 Is this permit in conjunction with a building permit? Yes ❑ No ili (Check Appropriate Box) Purpose of Building 'p(dS1...t.1Ad& Utility Authorization No. Existing Service__ Amps ' / Volts Overhead❑ Undgrd❑ No.of Meters __ New Service _ Amps / Volts Overhead Undgrd 0 No.of Meters _— NumberofFeeders and Ampacity n �t Location and Nature of Proposed Electrical Work: Eagii) e geh AGE. intior Com action o the ollowin:table ma be waived 6 the Ins.ecctor o Wires. ota No.of Recessed Luminaires No.of Ceil:Sus ,(Paddle)Fans No,of p Transformers EVA • No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- •No.ofEmergency Lighting No.of Luminaires Swimming Pool grnd. ❑ grnd. ❑ Batter Units No.of Receptacle Outlets No.of Oil Burners FIREALARMS No.of Zones No.of Switches No.of Gas Burners No.of etection andInitiating Devices el No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices Heat Pum Number Tons I No.of Self- ontained No.of Waste Disposers P'Number_ "" Detection/Alm Devices _ Totals: Municipal Other No.of Dishwashers Space/Area Heating KW Local 0 Connection 0 No.of Dryers Heating Appliances KW Security Devices Y g PP No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KWSigns Ballasts No.of Deuces or E uivalent • elecommunicationswiring: (>` No.IIydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent CY) 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 Ei BOND 0 OTHER 0 (Specify:) • I cut fy,under the pains and penalties of perjury,that the in ormation on this application is true and complete. Vo Vo FIRM : ; c 0 0.251.0.) •t.u. - . a- S1' I 10 40 ' LIC.NO.: y Licensee: (C4f}tL/) M fWft) Signature ,. / - 11C.NO.:21g✓_`l� ' (If applicable,en! "ex nut"f i the 1 cense wither line.) Bus.Tel No•150e r/t5 t Address: ' 14.14tU llat 500, t I4.IL' 1-4 l�1 ' 7' b 4'''.1" Alt Tel.No,:�— _�\`. *Per M.G.L.0.147,s.57-61,security wor requires Department of Public Safety"S"License: Lic.No. 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. . 4 A The Commonwealth of Massachusetts 1�' �: fDepartment oflndustrtalAccidents W• 1 Congress Street,Suite 100 ' t -""-'— = Boston, 102114-2017 ' %,,Z,0 M www.mass.gov/dia Workers'Compensation Insurance Affidavit:Qeneral Businesses.. TO BE FILED WITH THE ERMITTINGAUTHORITY. As sllcantInlOrmati0ri • 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#:508-394-7778 Are you an employer?Check the appropriate box: 1.12 I am a employer with Business Type(required): orpart-time).* �0 employees(full and/ 5. 0 Retail 2.0 Iamasole proprietor orpartnershi 6. QRestaurant/Bar/EatingEstablishment •• p and have no employees working for me in any capacity. 7. 0 Office and/or Sales(incl.real estate,auto,etc.) 3.0 [No workers'comp.insurance required] 8. 0 Non-profit We are a corporation and its officers have exercised 9. ❑Entertainment . their right of exemption per c.152,§1(4),and we have 4.❑ no employees.[No workers'comp.insurance required]** 10.[]manufacturing* We are a non-profit organization,staffed by volunteers, 11.0 Health Cara with no employees.[No workers'comp.insurance 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensationpolicy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization shoed check box#1. ' .l am an employer that is providing workers'compensation insurancefar my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: COMMONWEALTH AVE City/State/zip: CHESTNUT HILL,MA 02467 • Policy#or Self-ins.Lic.#1821A ExpirationAttach a copy of the workers'compensation policy dedarat on page(showing the policy number and expate: iration ation date). Failure to secure coverage as required under Section 25A of MOL 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cerd4 ,enalttes o perjury that the Information provided above Is true and correct. Si:nature: L .w one#•508-394-7778 Date: `] • Official use only. Do not write In this area,to be completed by city or town official City or Town: Issuing Authority(circle one): Permit Llcensa# • 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contactperson: Phone#: wwwmass.gov/dia