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Home My WebLink AboutBLDE-19-002088 ✓ �..� Commonwealthof Official Use Only t Massachusetts Permit No. BLDE-19-002088 • BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked JRev.1/07j 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:10/9/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 58 CROSS ST Owner or Tenant ZAMACHAJ RICHARD Telephone No. Owner's Address SPACE-ZAMACHAJ MELODY,58 CROSS ST,YARMOUTH PORT,MA 02675-1600 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 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- 1:1No.of Emergency Lighting title 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 1 KW No.of Self-Contained Totals: r Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ 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 ifdesired,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 ❑ BOND ❑ OTHER ❑ (Specify:) /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 Mt.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:$50.00 Commonwealth o/tr/addachudetto r O tci Use Only se e3~ v_-...,.„m: t cy� c7 Permit No. 9—e– /tel Cfi��SCL/{ e m' I! The artment o/Sire Serviced ti e� p a;N a' Occupancy and Fee Checked ' - , BOARD OF FIRE PREVENTION REGULATIONS [Rev. (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 27 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMAT ON) Date: /D////t City or Town of: qy/Cmvu7-(- (Pair. To the Inspector of Wires: By this application the undersign d gives notice of his or her intention to perform the electrical work described below. Location(Street&N er) 5$ C4%S 5rQC� C Svg/ Owner or Tenant �/ eta �yvfiet/6T Telephone No. 51?-35'7/ Owner's Address n t Is this permit In conjunction with a building permit? Yes ❑ No Eiv (Check Appropriate Box) Purpose of Building fp)'9JL1/06' Utility Authorization No. Existing Service_ Amps / Volts Overhead❑ Undgrd 0 No.of Meters New Service _ Amps / Volts Overhead❑ Undgrd❑ No.of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Ak/e,U . /belting/60/ 1 Completion of the following table maybe waived by the Inspector of Wires.0. Total No.of Recessed Luminaires No.of CeiL-Susp. Fans Transformersnf KVA P (Paddle) KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- No.of I mergency Lighting 1 No.of Luminaires Swimming Pool grad. ❑ grnd. ❑ Battery Units , No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and ,/J Initiating Devices IA No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons_ KW _ No.of Self-Contained Totals: - " Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Municipal ❑ Other P Connection C. No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent CD No.of Water No.of No.of Data Wiring: heaters Signs Ballasts No.of Devices or Equivalent 3 S No.Ilydromassage Bathtubs No.of Motors Total IIP telecommunications Wiring: 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 6 undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. (�V CHECK ONE: INSURANCE gBOND ❑ OTHER 0 (Specify:) W I certify,under the pains and penalties of perjury,that the information on this application is true and complete. (..\,a, FIRM FIRM NAM(Kg( l )(Q5LOW PLttomipo a- ften- /AL • LIC.NO.: _1C� Licensee: jaliehLQMtLVtR) Signature MCNO.:9/b'n (If applicable,ent3/'"exem t"in the license number line.) Bus.Tel.No.•SG8••j 9�'7775' Address: '5 /L2FYI--//ONCjRae- `,Pitffl [iIQ'tMowttr4amit 0>4k1 AIt.Te1.No.: *Per M.C.L.c. 147,s.57-61,security work requires Department of Public Safety"5"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)❑owner_ D owner's agent. Owner/AgentPERMIT FEE:$ SignatureTelephone No. ‘t, Pr + •7i. 1,1 __ The Commonwealth of Massachusetts it.o`–a—0 Department of Industrial Accidents ur. .ie,ilnl- a 1 Congress Street,Suite 100 = Ii_e Boston,MA 02114-2017 ' ,,_L�., www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:5083947778 Are you an employer?Check the appropriate box: Business Type(required): 1.El I am a employer with 10 employees(full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. 0 Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c.152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]" ILO Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees.[No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box HI 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 HI.. , I am an employer that is providing workers'compensation insurance for my employees. Below is tire 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.Lie.#1821A Expiration Date:01/01/209 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL 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 cerci the ails and nnaltiessoo perjury that the information provided above is true and correct Signature: ref—, Lam/--"'oleo-..- Date: 1 c7 /3/ / 12 phone#:508-394-7778 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.Licensing Board 5.Selectmen's Office • 6.Other Contact Person: Phone#: www.mass.gov/dia