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Home My WebLink AboutBLDE-19-001252 tedi Commonwealth of Official Use Only Massachusetts Permit No. BLDE-19-001252 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked (Rev.1/071 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 PR/AT/MINK OR TYPE ALL INFORMATION) Date:8/29/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice at his or her intention to pertomipe—ctegrIcat work described berg' Location(Street&Number) 16 WOODCREST LN ( (f' iA r• Owner or Tenant Telephone No. Owner's Address 16 WOODCREST LN,WEST YARMOUTH,MA 02673 Is this permit in conjunction with a building permit? Yes ❑ 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 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Replacement boiler. 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 0 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 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 \ ia'_p Permit No. '‘` E.. ( S` ThePartmeni oPlre Jeruica — Occupancy and a Checked ,J °,'� BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blenk) 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 ORMEALL INF RMATION) Date: I7-1 I v City or Town of: Oi'�Q v+]n To the Inspector of Wires: By this application the undersigned:rues notice o his or her i mention to perform the electrical work described bel.,. Q d r Location(Street&Number) . , i 0 r 1 k ' Q� / v 0 1 47 --r I • Owner or Tenant ' t t ` ( ILA � Telephone No. 1 ..`b1 Owner's Address A • ' � linina L I , Is this permit inconjuktionwicleabuildngperm ? Yes 0 No E (Check Appropriate Box) Purpose of Building OUR L 1O Vl pl Utility Authorization No. Existing Service_ Amps J/ Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead ElUndgrd❑ No.of Meter's — Number of Feeders and Ampacity ,I . Location and Nature of Proposed Electrical Work: 01 I b n I l e r I n S-It 1' }�'0/I 9 Com.letlon o the ollowin:table nm be waived 6 the fits iector o Wirer. o.of Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.ofl;mergency Lighting No.of Luminaires Swimming Pool grnd. ❑ grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS. No.of Zones • No.of Detection an No.of Switches No.of Gas Burners Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons ICW d No.of Self-Containe Totals: Detection/Alerting Devices Municipal Other No.of Dishwashers Space/Area Heating KW Local❑ Connection 0 HeatingAppliances KW Security Devices No.of Dryers pP No.of Devices or Equivalent No.of Water Nr No.of Data Wiring: KW Heaters Signs Ballasts No.of Devices or E uivalent elecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail ifdesired 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 �t coverage, is in force,and has exhibited proof of same to the permit issuing office. � 1•S CHECK ONE:,INSURANCE 0J BOND 0 OTHER 0 (Specify:) 1/4....0" ion U� I certify,under the pains anti penalties of perjury,that the in ormatton on this application Is true and complete. cJ.,A— FIRM NA F IJ 05100 • •.u/r- . a• ,e. r - ' LIC.NO.:� sir i_L�1.4-5 "n 0 Licensee{ ( " D / . Signature r % LIC.NO.59/82? . Q ajappllcable:enb m.t"in the 'censenu bet line) � Bus.TeL No: � Address: ; :ILiN . u JsfM' D �6 AltTel.No.: Ca— *Per M.G.L.c.147,s.57-61,security wor requires Department of Public Safety"S"License: Lb.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 I PERMIT FEE:$ Signature . Telephone No. SDa� a,n_ yvrr{,re sarrcueus, .04•0.1,J14.1.10,41•11.1.110 SF43 JabretO &W Department o rer 5 Fait 1/, f Industrial Accidents _;:lpl_ Office of Investigations •ci�ij_ • 600 Washington Street " Y Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers licant Information Please Print Le.ibl ame(Business/Organization/Individua]): E.c.yut tow � �0 ddress: ioaarl :t Q. b. g a 1 h t e. lit, ity/State/Zip:_5o„ .y„v ( , N Phone#:_ SUS-399-7 i 7p • e you an employer?Check the appropriate box: rI am a employer with 70 4. ❑I am a general contractor and I Type of project(required): Jemployees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction I am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Remodelng ship and have no employees These sub-contractors have working for me in any capacity, workers'comp.insurance. 8. 0 Demolition [No workers'comp.insurance 5. 0 We are a corporation and its 1 0 Building addition required.] officers have exercised their 0.0 Electrical repairs or additions J I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152, [N and we have no 12.0 Roof repairs insurance required.]t employees.Yees,[No workers' comp,insurance required.] 13.0 Other applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. • reowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indic • ating such. rectors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. an employer that is providing workers'compensation insurance for my employees. Below Ps the policy and job site motion. ance Company Name: mit( % y Mk/LOA S_l tivtt/1 auas.*1 y#or Self-ins.Lie.#: I$aI h • Expiration Date: (—I - aol9 Ste Address;._ , krbea-1 C / eh a copy of the workers'compensation policy declaration page(glowing the policy number y d expiration date). re to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a rp 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 to$250.00 a da a:ainst the violator. Be advised .t a copy of this statement may be forwarded to the Office of tigation • the DIA for insura r"- overage yeti a on. iereby certify �� penalties o"jury that the information provided above is true and correct. tic•- '_ e#: 1 - 79 — Date: I . i a01' i 'reial use only. Do not write In this area,to be completed by city,or tows:official or Town: Permit/License#uin Authority(circle one): oard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector they tact Person: ' Phone#: