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Home My WebLink AboutE-19-2183 a.► Commonwealth of Official Use Only Massachusetts Permit No. BLDE-19-002183 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 IN INK OR TYPE ALL INFORMATION) Date:10/12/2018 City or Town of: YARMOUTH To the Inspector of Wires: $ By this application the undersigned gives notice of his or her mtention to perform the electrical work described below. Location(Street&Number) 927=ROUTE 6A Owner or Tenant WESTERLY HOLDINGS LLC Telephone No. Owner's Address PO BOX 2000,BREWSTER,MA 02631 Is this permit in conjunction with a building permit? Yes ❑ 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: Replacement furnace. Completion of the,following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ce6: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- ElNo.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 0 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 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.: *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 44Zasc(9t(te et �m ~, q//q I fficialUse Only, Camntana as o�///aooachudeifa !t Ia M Permit No. V(-[� 1 2eparttrnent o/Jiro Services EE. _e. Occupancy and Fee Checked ,. s' BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank) • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code /5- 7 C),327 CMR 12.00 (PLEASE PRINTININKORTI�'EALL INFO IO / Date: lo! S / / g City or Town of: Yx(44/J/�iI To the Inspector of Wires: • By this application the undersigned giv s notice of hi r her intention to perform the elec i al wirk described below. Location(Street&Number) ' , 1 6 I i A T of / k I Q�'6 Owner or Tenant Nin in rO'lr•Pr Telephone No. 50`d 36a3000 Owner's Address G.`D e �/ Is this permit in conjunction with a building permit? Yes El No [17.- (Check Appropriate Box) c Purpose of Building Ci)inn erre t 4,1 Utility Authorization No. Existing Service_ Amps ' / Volts Overhead❑ Undgrd❑ No.of Meters __ New Service _ Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity 1 11 q I DIS Location and Nature of Proposed Electrical Work: (oG S f U trO'C fp -1 /7 `7 Cornsletiono the ollowin:table ma bewaived b the Ins sector o Wires. a No• .of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o.o p Transformers ICVA No.of Luminaire Outlets No.of Hot Tubs Generators ILVA Above In- No.of Emergency Lighting No.of Luminaires Swimming Pool Rind. 01 Rend. 0 Battery Units 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 Dis posers Heat Pump Number Tons ILW No.of Self-Containers P Totals: Detection/Alerting Devices Municipal Other No.of Dishwashers Space/Area Heating KW Local 0 Connection No.of Dryers Heating Appliances Key Security*stems:* y g PP No.of Devices or Equivalent No.of Water• No.of No.of Data Wiring: Heaters KWSignsBallasts No.of Devices or Eqyuivalent Telecommunications Wirin '43/4-4> --)--.0 No.IIydremassageBathtubs No.of Motors Total HP No.of Devices or Equivalent r• OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) .UM 0 Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. V— 1 INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless -J �J 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 E{ BOND 0 OTHER 0 (Specify:) • • I certify,under the pains and penalties of perjury,that the In ormatiort on this application is true and complete. FIRM NA : 'I k) NSLocd • "lj . a- 1e '-7 - 4,0 , LIC.NO.: ' `t.� 4 Licensee teFF n M W INSignature J/ � LIC.NO.aI s2T� • &applicable,enc//••"arem.t"in the license=fiber line.) 4 Bus.Tel.No:��68 � B Address: " L' ' ION G ILGI 'Pit As' C t4 • 0 kr Alt.TeLNo.: 'Per M.O.L.c.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 a:ent. Owner/Agent rligrZEINNIIIIM• Signature Telephone No. r , . • • t —ii-- The Commonwealth of Massachusetts 'Mi= t Department of Industrial Accidents STAKE 1 Congress Street,Suite 100 JJ Boston,MA 02114-2017 -tirLost www.massgov/dia Workers'Compensation Insurance Affidavit:General Businesses.. TO BE FILED WITH THE PERMITTING AUTHORITY, A. alicant Information Please Print Le i ibl • Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO.,INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664. Phone#:808394-7778 Are you an employer?Check the appropriate box: Business Type(required): 1.❑✓ I am a employer with 7o__employees(full and/ 5. 0 Retail or part-time).* • 2.0 I am a sole proprietor or partnership and have no 6 QRestauranf/Bar/Eat ng Establishment 7• Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity, 3.0 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 no employees.[No workers'comp.insurance required?* 10.0 Manufacturing 4.0 We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees.[No workers'comp•insurance req.] 12.0 Other *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. °If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. • I am an employer thong providing workers'compensation insurance for my 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.Lic.#1821A Expiration1/20 Attach a copy of the workers'compensation policy declaration page(showing the policy nu ber0and expiration 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 certi • • ,, ' ,enaltles o perfiny that the information provided above is true and correct. Sic store; ,«w s..ein Date: • I ''7 'hone#:508-394.7778 • 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/License# 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