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Home My WebLink AboutBLDE-19-000994 f • a Commonwealth of Official Use Only tbl Pillt Massachusetts Permit No. BLDE-19-000994 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked f Rev.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:8/20/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perlorm the electrical work described below. Location(Street&Number) 90 DEBS HILL RD UNIT 49A Owner or Tenant ROMANSON WALTER A Telephone No. Owner's Address DONNIS-ROMANSON MARY L,P O BOX 41,ASHBURNHAM,MA 01340 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 ❑ 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. 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- ❑ 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; 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 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 ❑ 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 (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:$50.00 LD tobbet _ommonwea_-- et ..,aeeaa_._etis /�' o ,�1 c /�` (� i^ refit t;� cc77 ��rl Permit No.a_q --C `ir?l ) `" 1 It JJepartmen.t entre...)ervicee f Occupancy and Fee Checked . tew rs' BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(lAZC),527 CMR 12.00 (PLEASE PRINT IN INK ORTI'F$ALLINF ( TIOM Date: v / /c I I City or Town of: \I/(if Ago t) To the Inspector of Wires: By this application the undersigned gives notice of his or he:intentio to .erfor the electric• work described below. Location(Street&Number I II • .t 5 I I I l iTl 0 4- . • Owner or Tenant l t f lid , / 2 Telephone No. 50%361 5-1?-0Owner's Address II 0 01 1 5 M 71/!/'1Y 1 )�L .9 - g n�l Is this permit in conJunctjon with(a building permit? Yes 9 No i_ (Check Appropriate Box) Purpose of Building W.{\`t (1 Utility Authorization No. Existing Service_ Amps / Volts Overhead 9 Undgrd❑ No.of Meters New Service Amps / Volts Overhead 9 Undgrd 9 No.of Meter's _ Number of Feeders and Ampacity r Location and Nature of Proposed Electrical Work: Gas Fuc,i ACP in Steil1 a I-i OH Completion of the following table may be waived by the Inspector 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 SwimmingPool Above ❑ In- 0 No.of Emergency Lighting . grnd. grad. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS. No.of Zones No.of Switches No.of Gas Burners No.InDetenand Initiatingon Devices No.of Ranges No.of Air Cond. Tons! No.of Alerting Devices No.of Waste Disposers Heat Pump[Number I Tons .IfKW tN`o.of Self-Contained p Totals:I— Detection/Alerting Devices No.of Dishwashers S ace/Area HeatingICW Local 0 Municipal 0 Other Space/Area Connection No.of Dryers Heating Appliances KW 'Security Systems:* Devices 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.Ilydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail ifdesired or as required by the Inspector of Wires. 0 Estimated Value of Electrical Work: (When required by municipal policy.) O Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. (I" INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless r (._(` the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The (tel undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. NI CHECICONE:.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. FIRM NA F V5l-0W • „� • e f. v' . • LIC.NO.: $l L LIC.NO.•:18n`� Licensce:�([,(}{)(Ln M waft) Signature �/ '/ (if applicable,ent "exem.t"inthe 'censen . ber line.) V Bus.Tel.No.•5t)8.394•'71' Address: : " IrL.ION . Li ;fit IIP ' 0 66 AItTel.No.: *Per M.G.L.c.147,s.57-61,security wor requires Department of Public Safety"5"License: Lie.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 PERMIT FEE: $ Signature . Telephone No. • Xaa A 1St. ' trismaVI6.Y646;, FJ t.1bJJ064/O.W{..O. 1 _ Department oflndustrialAccidents y 1-;:'lel Mil Office of Investigations t' 600 Washington Street til Boston,MA 02111 r`ng www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information c Please Print Legibly Varve(Business/Organization/Individual): E.c.WIA$1o,,,, Qi .joane{ n a 8 �<a�in �'a} lot. Address: <' Go-ciwi ( Q.' 0 7-ity/State/Zip: So.skin '(urs.,,c,,,kn tier Phone#: 538-39`1-17751 • re you an employer?Check the appropriate box: Type of project(required): I am a employer with 70 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 0 I am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 9 Demolition working for me in any capacity. workers'comp.insurance. [No workers'comp. 9. ❑Building addition p.insurance 5. 0 We are a corporation and its • required.] officers have exercised their 10.0 Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.9 Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.0 Other y applicant that checks box NI must also fill out the section below showing their workers'compensation policy information. • =owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. at an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 'natation. urance Company Name: f ktt ,.t Kite A f font Cewytvii icy#or Self-ins.Lice�.^^#: ($oZ I A • Expiration Date: (—I — a019 SiteAddress:a3 `ornmenwe0-1{y1 Ad-al C1' jrwl- NI City/State/Zip: Oa4' 7 ach a copy of the workers'compensation policy declaration page("showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 tp to$250.00 a da a:ainst the violator. Be advised .t a copy of this statement may be forwarded to the Office of estigations . the DIAfor insura. - overage veri a on. )hereby certify um, e airs a penalties o 'jury that the information provided above is true and correct. atuT: Date: I , i ash ne#: WLIVy- 777 ' 7ffrcial use only. Do not write in this area,to be completed by city,or town official • :ity or Town: Permit/License# 'ssuing Authority(circle one): • ..Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector i.Other :ontact Person: Phone#: