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Home My WebLink AboutE-19-2207 • ` Commonwealth of Official Use Only IE ` Massachusetts Permit No. BLDE-19-002207 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked LRev.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 intention to perform the electrical work described below. Location(Street&Number) 11 SEASIDE VILLAGE RD Owner or Tenant ALBEN ALBERT CHESTER TRS Telephone No. Owner's Address ALBEN JEANNINE HEBERT TRS, 11 SEASIDE VILLAGE RD,SOUTH YARMOUTH, MA 02664 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: HVAC replacement. 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 Arnd. 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 Mr Cond. 1 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 ❑ Other: Connection No.of Dryers Heating Appliances KW Security Systems:" No.of Devices or Equivalent No.of Watery 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:$50.00 tyecl—$ . ] (I 'eI( 6 - C//�� /r, �/1/I // OfficialUse Only ommanwea(ih o/rr/aoaachuoeitd �j 2.0 - si cy c7 n Permit No. C/ ' !E tic Tepartment o/,}ire Jerviced 1-2 Occupancy and Pee Checked �.,Jnr® BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07) (leaveblank) — • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK /1 ' All work to be performed in accordance with the Massachusetts EledriealCode(MEC),j 7CMR12.00 r (PLEASEPRINT IN INK OR ALL INFORMATION Date:a--_ f 1 City or Town of: . f troy+i't To the Inspector of Wires: • By this application the undersigned givesnotice•of is or her in'e,tiontoperfot th•electrical work descri.edbelow. ` 1£€9 LD'cation(Street&Nu her) 'aS e k r U ea r t Owner or Tenant Nth -- A e{e Telephone No.50 01 Owner's Address sat Is this permit in conjunction wit a building permit? Yes 0 No `Check Appropriate Box) Purpose of Building ' Owe (iii Utility Authorization No, Existing Service^ Amps • / Volts Overhead 0 Undgrd 0 No.of Meters __• New Service _ Amps / Volts Overhead Undgrd❑ No.of Meters Number of Feeders and Ampacity LocafionandN•tare oYProp I.ed Electrical Wor}r: S �t!//!A. a i OA_ er !n J . _ 6n Con ulettono the oilman;table in' bewaived b the Insactor o Wires. No.of Recessed Luminaires No.of Ceil.Saddle p (P )Fans KVA us . o.of • Transformers No.of Luminaire Outlets No.of Hot Tubs Generators KVO` Alp. I. No.of Emergency Light nl No.of Luminaires SwimmingPool rnd.ove El : nd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones • No.of Switches No.of Gas Burners No.of Detection andInitiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers —IleatPumpNumber Tons paNo.of Self-Contained--- Totals: I r Detection/AlertinOevices No.of Dishwashers Space/Area Heating EW Local❑ Municipal0 OtherConnection No.of Dryers HeatingAppliances KW Security of Devices rY PP No of Devices or Equivalent • No.of Water No.of No.of Data Wiring: Heaters KW Ballasts No.of Devices drE•uivalent Si ns e ecommumeations f irin bro.Hydromassage Bathtubs No.of Motors Total BY No.of Devices or Equivalent • OTHER: Attach additional detail if desirecb 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 accordancewithMECRule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may Issue unless 1p a the licensee provides proof of liability insurance Including"completed operation"coverage or its substantial equivalent. The _—i undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE g BOND 0 OTHER El (Specify:) Cr ..f.. • I certify,under the pains and penalties of perjury,that the information on this application is true and complete `� J" Cn FHtM NA t!D NSLou I, . (a s ep J 45 '0 ' LIC.NO.: 3 `z l Cet 1. 0 Licensee: taEar2n MtWuO Signature .J LIC.NO.:____ "1' (If applicable,enh "exem,:"in the license nuiliber line) I Bus.Tel.No... tc Address: • " 4.' /0/t) n 6 gat. 5 1, r ott pith'' 0 t€ Alt.Tel.No.:—_— *Per M.O.L.c.147,s.57-61,security wor requires Department of Public Safety"S"License: Lie.No. _______— OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally • fequired by law. By my signature below,I hereby waive this requirement. I maths(check one Downer 0 owner's a ent. Owner/Agent PERMIT FEE:$ Signature Telephone No. / r ' + • V 6 Y �l • • t �[ The Commonwealth of Massachusetts o •=.4,1---§ • DepartmentfindustriatIccidents I'na f 1 1 Congress Street,Suite I0O J Boston,111.4 02114--2017 • rte,•' ' '� .Workers' WWw..nwss.gov/dja '• , Compensation Insurance Affidavit:General Businesses.. TO BEBUD Wl1HTHEPERMITTING AUTHORITY. Business/OrganizationNome;E.F.WINSLOW PLUMBING&HEATING CO.,INC i AaI!leantlnformation Please Print Le.ib1 • Address:13 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664. Phone#:508-394-7778 Are you an employer?Check the appropriate box: L[J] Iamaempfoy rwith''�(� Business Type(required); or parbt me).� "_ -employees(full and/ • 0 Retail. . 2.❑ I am a sole proprietor or partnership6. QRestamant/BarBating Bstablishment • employees and have no working for me in any capacity. 7. 0 Office and/or Sales(incl.real estate,auto,etc.) 3.❑ [No workers'comp,insurance required] 8. 0 Non-profit We are a corporation and its officers have exercised 9. 9 Entertainment • their right of exemption per c.152,§1(4),and we have 4.0 no employees.[No workers'comp.insurance required?* 10.0 manufacturing We are a non-profit organization,staffed by volunteers, 11.[]Health Care with no employees.[No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box dl must also fill out the section below showing their compensation organization should officers have peasaflonpolcy infoimation. organization shouldfiers box exempted elves,but the corporation has other employees,aworkers'compensation policy is required and such an • Inns employer that is providing workers'compensation Insurance for my Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY employees. Below is the policy information • Insurer's Address:23 COMMONWEALTH AVE City/State/Zip; CHESTNUT HILL,MA 02467 • Policy#or Self-ins.Lic.#1821A Attach a copy of the workers'compensationpolicydeclarationpage(showing the pol cynu ber0and0xxpiationdate). 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Zdo hereby cern :. q1e—Q yrs and.enallles o perjury that the information provided above is true and correct SI: ature: ' - t+ti 'hone#.508-394.7778 Date: - • Official use only. Do not write in this area,to be completed by city ar town official • City or Town: Issuing Authors Permit/License# t3(ch cle one): • 1.Board of Health 2.BuildingDepartment3.C;tytpo Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person' Phone#: wwwmess.gov/die