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Home My WebLink AboutE-19-322 ✓, ark Commonwealth of Official Use Only FE..Z►� Massachusetts Permit No. BLDE-19-000322 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked (Rev.l/07] APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK An 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:7/16/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to electrical work gescribed below. Location(Street&Number) 1329 ROUTE 28 LtEg Owner or Tenant SURPRENANT WILLIAM J TR Telephone No. Owner's Address BISQUE BOY RLTY TRUST, 1329 ROUTE 28,SOUTH YARMOUTH,MA 02664 Is this permit in conjunction with a building permit? Yes 0 No ❑ (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 O No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Replacement 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 Above ❑ In-nd. ❑ No.of Emergency Lighting Battery Units '�I grnd. gr No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones 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 Totals: Detection/Alerting 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 No.of Water 1 KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total IIP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail fdesired,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.: Ter M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"5"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 SignatureTelephone No. PERMIT FEE:$80.00 ek.)N 10/31 (16 flzS I /J Ae,� a qq//�i�� II Official Use Only __._ Commonwealth o/' /r/aosachudettd ,BfaScc�'� cc77 ((�� Permit No. en -O'32Z �1_ 1Jepartmen/of Jiro Serviced - -.I'll—W9 Occupancy and Fee Checked -** y o BOARD OF FIRE PREVENTION REGULATIONS [Rev. t•� (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(M�C),52/y CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFO ION) Date: -7 0/ f ? City or Town of: t I j/n ,(t SOL --) To the Inspector of Wires: By this application the undersigndd gives notice of his or her intention—to perform the electrical work described below. Location(Street&Numm/ber) /,3.P9 ra Z$ (cc ) Owner or Tenant a 1..-`Li.S `GSj lit.C/Lfi`sU/— Telephone No. 16;0.7CCV Owner's Address e ,�,/ Is this permit in conjunction with abuilding permit? Yes ❑ No Lr (Check Appropriate Box) Purpose of Building (10,0,0e,26,4--e__ Utility Authorization No. Existing Service_ Amps / Volts Overhead El 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: I�L (/RA: n, I/zrf Wt7ti/C 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 F� No.of Luminaire Outlets No.of Hot Tubs Generators KVA V'. Above In- No.of Lmergency Lighting No.of Luminaires Swimming Pool gr.nd. ❑ grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones and No.of Switches No.of Gas Burners No.In InitiatinggDetection Devices 1 Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices •J 1 Heat Pump[NumberTons K_W_ __ _ No.of Self-Contained (. No.of Waste Disposers Totals:[ -- u Detection/Alerting Devices M No.of Dishwashers Space/Area Beating KW Local❑ Connection 0 Other 1No.of Dryers HeatingAppliances KW Security Systems:* No.of Devices or Equivalent No.of WaterKWNo.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or El uivalent No.II dromassa a Bathtubs No.of Motors Total HP Tilecommunications Wiring: Y g 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.) fff/ 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 EtBOND 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 :: is tv(Io✓st-0W pc.tfo131p(9 e. Reil- 1 lIX • LIC.NO.: (31C.-- Licensee( 31CiLicensee( ,(Ct4q(1..Q /14 tLVfit) Signature LIC.NO.:9/67Y (If applicable,ent `exem t_' in the license number line) ,/ Bus.Tel.No.•joS•/94.7778' Address: '3 /LterLeoN Clitat `Joitt*4 1p4'tMoittri, rife 07-4' Alt.Tel.No.: *Per M.G.L.c.147,s.57-61,security won(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 PERMIT FEE: $ Signature _ Telephone No. • YA. \ al• '-V wIVrf.N&LI• ,J ua,.J.nn.,.HJfsw ♦ '••� db Department of Industrial Accidents "4 WSJ 600 Office of Investigations ,_ J 600 Washington Street eif Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� 1 Please Print Legibly •Name(Business/Or/g��anization/Individual): E.c.Wtn5IQv) 910e.. I7unc`Ia Qe.) ,n( , Address: g typo- w'i �';Rier 1JX City/State/Zip: Sou n MA' Phone#: '5U5- 399-117S/ Are you an employer?Check the appropriate box: Type of project(required): Xam a employer with 10 4. ❑ 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 Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 1.❑ 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' comp.insurance required.] 13.0 Other thy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • Homeowners 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. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. //�� isurance Company Name: fky13 ) f'10kcLA IfLwtknCP_ Cakeykkili olicy#or Self-ins.Lic.#: I '3 a 1 A 11 Expiration Date: I—I - aO19 )b SiteAddress:. 3 Cran ."cvflwh Au-41e0-)4i4� C4'eg� YI1II City/State/Zip: Oa4(o7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a ne 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 f 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 ivestigations r the DIA for insurar - overage verif a,on. do hereby certify un • e ains a 'penalties o p jury that the information provided above is true and correct ignatuitc Date: la) 31 I aou hone#: cbt 3S'4. 7 978 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#: