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Home My WebLink AboutBLDE-19-002316 ► a. Commonwealth of Official Use Only `Ef Massachusetts Permit No. BLDE-19-002316 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked JRev.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/N INK OR TYPE ALL INFORMATION) Date:10/18/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice or his or her intention to pertomr the electrical work described below. Location(Street&Number) 12 MISTLETOE LN Owner or Tenant MADDALENA ALFRED A Telephone No. Owner's Address MADDALENA BERNADETTE L, 12 MISTLETOE RD, SOUTH YARMOUTH, MA 02664-2505 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 ❑ 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 gird. gird. 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 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 (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.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 O 9 (c[s (66 • �-\ CommonweaCtlaof rr/aeeaehueetfa O^fficialUse0 Z/ `� 1 -_ a ccyy cc77 Permit No. 11' 0 `t--=.11.w.w' e[Je artment o/,}ira Services r o-5 POccupancy and Fee Checked • ° , '. BOARD OF FIRE PREVENTION REGULATIONS [Rev 1/07] (leaveblank) • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cod I'C),527e MR 2.00 (PLEASEPRINTININK ORALL INFORMATION) Date: II I City or Town of: T_;I /j_____ To the Inspector of fres: By this application the undersig,ed gives notice of is or her intention to.e form the electrical work described below. Lc'eation(Street&Number) Ld�C t OU+R a Owner or•Tenant :'(i g I y ,_, N ' at TelephoneN6.5111,11559_15.9 Owner's Address 51M9 Is this permit in conjunction with a building permit? Yes 0 No (Check Appropriate Box) Purpose onuildingt 1�\, Utility bvl �{ 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 r ` € i iLa Location and Nature of Proposed Electrical Work: Gp.S ft/(AKR.- in-r^' u • i i r • Coln.letiono the oilowin:table in. bewaived b theins,s ro Wires. No• .of Recessed Luminaires No.of Ceil Sus .(Paddle)Fans oa of p Transformers EVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Shove In- 'No.ofEmerSency Lighting No.afLuminaixes SwimmingAHA . nd. ❑ : nd. ❑ Batter 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 No.of Alerting Devices No.of Waste Disosers Pinup[Number lions FW oniTotals:I Detection/Alert:n9 Devices - No.of Dishwashers Space/Area Heating KW Local❑ ConMuninciectpiaonl 0 Other HeatingAppliances IC security Systems:* No.of Dryers PP No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Egu valent Telecommunications Wi rr g No.Hydromassage Bathtubs No.of Motors Total HP 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: 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 ad BOND 0 OTHER 0 (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete CZ N • LIC.NO.: "tom FIRM NA� ., � ft) NStow • .ul� Ir �' �1' � �O • Licensee: ( M ti.Vtio Signature ./,, r " LIC.NO.:t215'2' 7/1 �a • (Ifapplicable,em "exem.t"In the license n bei line.) �' Bus.Tel.No.''�6 i • Address: / /129 G Kat 5vu. A t cit Art bAlt.Tel.No.:---- y� *Per M.O.L.c.147,s.57-61,security wor requires Department of Public Safety"S"License: Lie.No. ____.-- OWNER'S OWNER'S INSURANCE WAIVER: I am aware that the Llcensee 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)❑owner ❑owner's agent. Owner/Agent • I PERMIT FEE:5 Signature Telephone No. joLit . v, • • • A t __ate! The Comnwnweaith of Massachusetts 1='41M gt • Department of Industrial Accidents t� q 1 Congress Street,Suite.100 'x— p# ' Boston,MA 02114-2017 • `�"' wwty mass goo/die Workers'Compensation Insurance Affidavit:GeneralBusinesses.; ' ' TO BE MED WITH THE PERMITTINGAUTHORITY. A r Ilicant Information 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.DJ I am a employer with Business Type(required): . or part-time).* employees(full and/ 5. ❑Retail • 2,® I am a sole proprietor orpan6. DRestaurant/Bar/Eating Establishment • employees working for me in any cap dty. no 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. ❑Entertainurent • their right of exemption per c.152,§1(4),and we have 4.0 no employees.[No workers'comp.insurance requiredj+# 10.0 Manufacturing 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#1 must also tat out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselyea,but the corporation has other employee;a workers'compensation policyis organization should check box Ml. ileus required and Buchan ' X am an employer that is providing workers'compensation insurance for my employees. Below Ls the policy hiformation.ARROW MUTUAL INSURANCE COMANYInsurance Company Name; Insurer's Address:23 COMMONWEALTH AVE City/state/Zip: CHESTNUT HILL,MA 02467 Policy#or Self-ins.Lie.#1821A Expirationate:Attach a copy of the workers'compensation policy declaration page(showing the policy number0and 1/2expiration 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 • I do hereby cern nahies o perjury that the information provided above is true and correct Si_nauue; ,....n oa,� ri 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 • Author( Permit/License# Authority • 1.Board of Health 2.Building Department 3.City/Town-Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: wwacmasa.gov/die