The URL can be used to link to this page

Home My WebLink AboutBLDE-19-002444 Commonwealth of Official Use Only ,/ 8Massachusetts Permit No. BLDE-19-002444 �—' BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked JRev.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:10/24/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to ptWOp�the electrical work(nibed below. Location(Street&Number) 2 SQUANTO RD .1/A--U ID l�f Jx Owner or Tenant GRIBBONS THOMAS R Telephone No. Owner's Address C/O R BARBIERI/THOM R GRIBBONS,50 RICH ST,WORCESTER, MA 01602-1202 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: Septic pump&alarm.Receptacle for water heater. 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 Abov.e ❑ Igrnn-d. ❑ No,of Emergency Lighting _ grndBattery Units No.of Receptacle Outlets 1 No.of Oil Burners FIRE ALARMS No.of Zones fa 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 1 P Totals: Detection/Alertine 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 A No.of Water , No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.hydromassage Bathtubs No.of Motors 1 Total HP Telecommunications Wiring: ^C4 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 LI (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Lawrence R Brown Licensee: Lawrence R Brown Signature LTC.NO.: 30708 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:. Address:30 LIMERICK CT,CENTERVILLE MA 026322713 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 Telephone No. PERMIT FEE:$50.00 DikLb (0(-Ki i e • ,I 'as ze, • Commonwealth of Massachusetts OfficialOiUse Ont . p Department of Fires Services Permit No. ` ' r2 `f 4 E tl)� Occupancy and Fee Checked i);- BOARD OF FIRE PREVENTION REGULATIONS •e (Rev.9/05) (leave blank) , • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),5r17 CMR 12.00 ik (PLEASE PRINT ININK ORTYPE ALL INFORMATION) Date: QGT ,21-/ - a20/ � City Or Town of: its /ARt VOtI T/! To the Inspector of Wires: ft By this application the undenig�ned gives notice of his or her intention to perform the electrical work described below: Location(Street&Number) •f* 2. So& A//To — ,4ii. li Owner or Tenant --p4VI D Cid X Telephone No. Owner's Address S4'Nlf • -- Is this permit in conjunction with a building permit?do r Yes.Cg No 0 (Check Appropriate Box) Purpose of Building (A)I R E SEp nt... 74 nb4-12?Z Utility Authorization No Existing Services /00 Amps /a-O/�)wVolts Overhead 0 Undgrd❑ ' No.of Meters / New Service = Amps / Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity 3u) /00.4 Location and Nature of Proposed Electrical Work: W/RC SEgr/G .4.4/(/17 / /4l 4910 $7-4// ON r/e/ Foie A'r td-Tent Completion of die following table nary be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cal:Susp.(Paddle)Fans No.of Tranformers HVA No.of Luminaire Outlets No.of HotThbs Generators KVA I No.of Lumbudres Swimming Pool gradd. ❑ ity ❑ Baatterr links r Lighting 1O No.of Receptacle Outlets / No.of Oil Burners FIRE ALARMS No.of Zones �� No.of Switches No.of Gas Burners • Na of Detection and �tyInitiating Devices No.of Ranges No.of Air Cond. Total m No.of Alerting Devices t -r Heat Pump Number Tons KW No.of Self-Contained • �( o ask Disposers Totals: Detection/Alerting Devices W m Ni-o ishwashers Space/Area Heating KW. Local❑Mnnicipd ❑Ower, IN. Connection . - N ec Beating Appliances KW Security Sntems:• v ear,oyll ryetE g PP Na o!lievicrs or Equivalent W oL e er KW No.of No.of Data Wring:. Iill eaten Signs Ballasts No.of Device;or Equivalent u v Telaommunintions Wirin : V LI $ dromassage Bathtubs No.of Motors / Total HP /i.• No.of lkvices or Equivalent W C 1iH R: IX �roSAttached additional detail If desired,or as required by the Inspector of Wires. • d Value of Electrical Work; �0 (When required by municipal policy.) Work to Start /0- 24 -I B- Inspections to be requested in accordance with MEC Rule ID,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 Erl BOND 0 OTHER❑ (Specify:) I tenth,under the pains and pens_'es of perjury,that thein formation on this application is true and enmplete. FIRM NAME: G4R2 /Loa)e✓ 4/fir c-/4/✓ LIC.NO.: 3 070e Licensee: 4 /R ! '/ . /t/ Signature LIC.NO.: (!!applicable.enter"exe,npt"in the license number lion).,,.., Bat.TeL No.: Address: 30 Lsmn7nofr/c CT /✓777'//% Oa637-Alt.Te.No.: .0.e aa1-7263 'Security System ContractorLicense required for this work;if applicable,enter the license number here: OWNER'S INSURANCE WAIVER:I em aware that the Licensee doer not have the liability insurance coverage normally required by law.By my signature below,I hereby waive this requirement.I am the(check one) Downer Downer's agent Sigent D Signature Telephone No. PERMTI'FEE:$ Jll . k• W.1..;i,,.,1,, ) - ' The Commotnvealtlr ojMassaehrtsetis r r • Department oflnrre oef i::16. X Congress Street,Suite 100 # Roston,d14021I4-2017 ,ra wwlv.nrass_gov/die Worlcers:Compensation InsuranceAffidavit:Builders/Contractors/LllectriciansRltrmbers. TO 112 DIED 1VITh(TAR PEUl U 1INO AUDIOR1TY. Applicant Information Please Print Legibly Nan>e @Dusincss/Organrationlndividual): Lfl'4Zy SZO&A • CrAny C)4i) Address: 30 Li MERic-A CT n L City/State/Zip: (�eit/Tr l////ems /7#1- hone#: bed if -c?-. 1->2e 3 Are you an employer?Check the appropriate bot • Type of project(required): l..I am a Employer with I employees(full and/orpart-time).* 7. ['New construction • 2.0 Lam a solo propridor orparinczship and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required] 3.01 ani a homeowner doing ill work mysei([No workers'comp.insurance required]I 9. ❑Demolition 4E1 am a homeowner and will be hiring contractor to conduct all work on my property.1 will 10 Building addition ensure that all contactors either have workers'compensation insurance or are solo 11.0 Electrical repairsor additions proprietors with no employees. . 12.❑Plumbing repairs or additions 5.0I am a general contrs4or and 1 have hind the sub-conbacturs listed on the attached shut. 13.0Roofrepairs • These sub-contractors have employees and have weaken'comp.insurance 6.0 We are a eoporation and its officers hive exercised theirright of exemption per MQ.c. 14.QOther 152,41(4)•and we have no employees.[No workru'comp.Insurance fequircd] • • • *Any applicant that checks box 01 must also fill out the section below showing their aortas'compensation policy information. t Honcmvnea who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such. /Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees If the sub-contractors hen employees,they must provide their workers'comp.policy member. lamanmrplayerMal 1sprovldiagiporkers!compensation insnrancefarnryemployees. Delon,Li the policy andjob sift infornsatlon • Insurance Company Name: 71E //41TFr/R0 .Ajc Policy#or Self-ins.Lia#: Expiration Date: d o 1 9 Job Site Address: 4 a VZL/1dTD City/StatetZip:2m&G!/// Attach a copy of the workers' pensationpglicydeclarationpage(showingthepolicyn ber and expiration date). Failure to secure coverage as required under MGL a 152,§25A is a criminal violation punishable by a fine up to$1,500.00 . and/or one-year imprisonment,as well as civil penalties in the foot of a STOP WORK ORDERand a fine of up to$250.00 a day against the violator.A cgpy of this statement may be forwarded to the Office ofhmrstigatious of the DIA for insurance coverage verification. . Ido hereby erti ndcetlsepainsandpenaltiesofperjuryshaltkeinformationprovideedaaboveistrueandcorrect. • signature: i e e, )34,6 4. Dec: l t d..4 a0 / g phone#[ 0.2,6 / Official use only. Do not write in pir area,to be completed by city or tot on officiaL • Qty or Town: Permit/L[cense# Issuing Authority(circle one): LBoard ofHealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PlumbingInspector • 6.Other Contact Person: Phone#: