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Home My WebLink AboutBLDE-19-002465 Commonwealth of Official Use Only Massachusetts Permit No. BLDE-19-002465 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.l/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:10/25/2018 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) 42 NORTH RD Owner or Tenant DUBOIS RAYMOND L Telephone No. Owner's Address DUBOIS CLAIRE G,42 NORTH RD,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 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 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 ove 0 ln- ❑ No.of Emergency Lighting Abgrnd. 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 Ileating 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 IIP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail tides:red,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 ❑ 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 7,(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 S tt( 7(( g /� �/ / t� ----------- Or 0ni ,. l•.arninalEWeaLWb a� aGlacfWdeilJ ^ / y t -se PermtNo. ski : c� (� y/ E _fit_ TUepartmenfo/�in eraices l)ecupancyandFeeChecked —s BOARD OF FIRE PREVENTION REGULATIONS Occupancy peaveblank) • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ' All work to be performed in accordance with theMassachusetta Electrical Cods(MEC,527 704 (PLEASE PRINT IN INK OR TOR ALL 1ORMATION) Date: n � V City or Town of: armevrL, To the Inspector of Wires: • By this application the undersigned glivestnplice of his o er'ntentionto arfo.rmthe electrical y/-/--4�-'-'""'"'°low. . L'ocation(Street& umber) 0s Nor d West YafNn*k ✓0 6-13 Owner or Tenant TelephoneNo. Owner's Address t Is this permit in conjunction wig:a building permit? Yes El No L (Check Appro riat9Box) r Purpose attuning ht/E b /n Utility Authorization No. t 17 S x'11 a7 Existing Service_ Amps / Volts Overhead 0 Undgrd 0 No.of Meters New Service _ Amps I Volts Overhead 0 Undgrd 0 No.of Meters __ Number of Feeders and Ampacity f,t I Location and Nature of Proposed Electrical Work: 15 oiler S/ane ( en Coln detiona the allowin:table in, bewaivedb the Ins lector o Wires. No.of Recessed Luminaires No.of Ceil:Sus .(Paddle)Fans Transformerss o a p INA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.of Emergency Light ng No.of Luminaires Swimming Pool grnd. 1-1 grnd. 0 Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones • No.of Switches No.of Gas Burners No.of Detection anInitiating Devices No.of Ranges No.of Air Cond. Tony No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons__„IBJ No.of Self-Contained P Totals: Detection/Alertiugpevices Municippal Other No.of Dishwashers Space/AreaHeating KW Local❑ Connection 0 No.ofDr Dryers HeatingAppliances KW �ecoy SDalces* Y PP No.ofDevlcesorEquivalent No.of Water No.of No.oY Data Wiring: Heaters KW Signs Ballasts No.ofDencesorE nivalent Telecommunications wing No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail iildesired,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. 0 • . CHECK ONE: INSURANCE E1 BOND 0 OTHER 0 (Specify:) cfV ' • I cert,under the pains and penalties ofperJury,that the information on this application is true and complete. FIRM NA C ft) 051.,0 ) eG . 4- e, ,i - Co . LIC.N04 ? t i % - LIc.No.:a91 g�`l� L[censee: ((,((-{�(LQ /14GLVJN Signature ,.f 6_,L° . '•'j—crs (II pp Bus.Tel.No.: a8r� � a flenble,enh 'ex-m.t"in thehe[lcensen berllne.) • Address: ;L Is JON oil(ae `J Olt f4 a / OW ti A ' 0 b/ Alt.Tel.No.:-_-- C' 0 0 *Per M.O.L.c,147,s.57-61,security wor requires Department of Public Safety"S"License: Lic.No. Q ? v 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 • PERMIT FEE:$ n' Signature TelephoneNo. • Y a .". ••A 1 f , The Commonwealth ofMassac&usefts -,fir '•�epm'ttn'ent of lndusiriaiAccidenfs .,_il` I, I CongressSfreef,Suite 100 t Boston,ll?A 02114-2017 • , • Jr Workers'compensation rP�'r WWWmaSS.wo,/die': . ' Com ensationInsuranceAffrdavit:General$nsinesses.. .'. ?; TO BEMED WITHTHEPERNMTINGAUTHORITY, • Ay ylicantinformation Please Print Ie ribl • Business/Organization Narat;E.F.E.F.WI_. SOW PLUMBING&HEATING CO INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02684. Are you an employer?Check appropriatethe Phone#:808394-7778 1. `I am a employer with box: Business Type,(requijed): • or part-time �_employees(fulland/ 5. 0 Retail 2.0 I am a sole proprietor or partnership 6. QRestaurantfBaz/Eating Establishment employees working for Inc in an wand have no • Y pacify. 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. 0 Entertainment • their right of exemption per c.152,§1(4),and we have no employees.[No workers'comp.insurance required?* 10.Q Manufacturing 4. We are a non-profit organization,staffed by volunteers, 11.0 Health Care El with no employees.[No workers'comp.insurance reg.] 12.0 Other •Any applicant that checks box#1 must also fill autihe *Alftheclipomteaave exempted section below showing theirworkere'compensation policy intoimation. organvanceshould check box#1. p themselves,but the corporation has otheremployees,aworkers'compensa5on policy ur«ryired and such an ployerthat&providingworkers compensation insurance for;qv meemployees. Below is Me policy information. Insurance Company Na :ARROW MUTUAL INSURANCE COMPANY Insurer's Address:23 COMMONWEALTH AVE City/state/zip: CHESTNUT HILL,MA 02467 • Policy#or Self-ins.Lie.#1821A Eirationoit Attach a copy of the workers'compensation policy declaration page(showing the policy numberate: 01/2 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ida hereby cern . :• ' ,, ' enalile4 o perjury That The Information provided above is true and correct Si: store: '.one#:508-394-7778 Date: - I. Official use only. Do nal write In this area,to be completed by city or town official • City or Town: Issuing Authori Permitaitcense# ( • 1.$oardofliealthg De2.$ufidiu 6.Other Paritnent 3.CYtY/Town Clerk 4.Licensing Board S.Sefecfinen's Office Contact Person: Phone#: www.mass.govtdla