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Home My WebLink AboutBLDE-19-002535 AS Commonwealth of offteialUse Only f ti Massachusetts Permit No. BLDE-19-002535 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 INFORMATIOM Date:10/29/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pertorm the electrical work described below. Location(Street&Number) 20 CAPT NICKERSON RD Owner or Tenant SUTCLIFFE JILL M Telephone No. Owner's Address 20 CAPT NICKERSON RD,SOUTH YARMOUTH,MA 02664 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 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 ❑ Ir ❑ 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 ❑ 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 ❑ 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 Official UseOnl �` Cow & / �aaae t (r cy c7 PermitNo. • p=�L; .Ueparlmani ei.2a Serviced le. P v Occupancy and Fee Checked _C _" BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] eaveblan (lk) • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK • All work to be performed in accordance with theMassachusetts Electrical Code(MEC),527 or 12� (PLEASEPRINTDTINICOR E.4LLIN ORMATIO11) Date: li f a City or Town of: d To the Inspector of Wires: By this application the undersigned gives notice o histolher intentionto perform the elec 'cal work descr y d below. . Lo'daf on(Street&Number) 1V k C6 TelephoneNc:L O�3 q� Owner or Tenant : :ate 1 Cif f Owner's Address Is this permit inconjunction with abuilding permit? Yes El No (ChecicAppropriateBox) PurposeoYHuilding t.3'�\VtA Utility AnthorizationNo. Existing Service_ Amps ' / Volts Overhead trudged 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: 6j •e , hel-Ptt Completion of thefollowingtabkma bewalvedb thelTQ-torof-res. No.of Recessed Luminaires No.ofCer7.-Sus .(Paddle)Fans rani p rvice Amps ' ICVA No.of Luminaire Outlets No.of Hot Tubs Generators e---_—_-_ Above in- 'No.of Emergency Lighting No.oYLuminaires Swimming Pool grnd. 0 grad. 0 BatteryUnits No.of Receptacle Outlets No.of Oil Burners FERE ALARMS INo.of Zones No.of Detection an • No.of Switches No.of Gas Burners In tiating Devices No.of Ranges No.of Air Cond. Total No.of AIerting Devices Tons No.of Waste Disosers Heat Pump )umber.Tons I(W No.of5elfntained p Totals: Detection/Alertin Devices M No.of Dishwashers Space/Area Heating KW Local Conneclunicippal lost 0 Other Security Systems:" No.of Dryers Heating Appliances KW No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters TCS Sins Ballasts No.ofDevicesorE_ Iuivalent -e ecommunications irisg: • No.Hydromassage Bathtubs No.of Motors Total UP 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: INSURANCB E/� BOND 0 OTHER 0 (Specify:) -3- Icart fy,under the pains and penalties of perjury,that the information on this application is true and complete. .-- 0 FIRM NAME: c to NStow i mudF . e.. s ' r - LIC.NO.: LIC.NO.:o`1 J 8__'`T� r fapplee:�i- met M.elLV((U Signature l / Bus.Tel.No.• .. (7faPPllcadle,emrr"ex-mat"fn the license nu der line) Address: - L. 4g Anti( gat 5vit ;■t brit 0,,,,t 0 b AItTel.No.:_� *PerM.O.L.c.147,s.57-61,securitywor requires Department of Public Safety"S"License: Lic.No. e7 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally LJ• fequired 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:$ Signature Telephone No. • A !l 1 cThe Commonwealth o M� fMassacliusetty �a .Department of lndustrialAccidents • 1,EViroMill01 1Congress Street,Siate100 • rr, • Boston,DIA 02114--2017 • Workers' www,massgov/dia Compensation Insurance Affidavit:General Businesses.. A,alicantInformatiott TO BE TBZ PERMITTINGAUTgORTTY, Please Print Letibl Business/Organization Name:E.F.WINSLOW PLUMBING&HEATING CO.;INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664. phone#:508394-7778 Are you an employer?Check the appropriate box: 1.[] I am a employer with Business Type(required): or part-time)• employees(foil and/ 5. 0 Retail • 2.0 lam asole proprietor orpartnership andhavano 6. ORestaura Ynar/EatngEstablshment ' 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 3.0 [No workers'camp.insurance required] We are a corporation and its officers have 8. 0 Non-profit • their right of exemption per c.152, exercised 9. 0 Entertainment §1(4),andWahave no employees.[No workers'comp.insurance requ redj+ 10.[] eanufactre ng 4.0 We are anon-profit organization,staffed byvolunteers, II•[�IlealthCare • with no employees.[No workers'comp.insurance *Any applicantthat checks box#1 must also fill out the .] 12.D Other ' a�the corporate off ,have exempted themselves, section belowshowin organization should check box#l. �.but the w 8heremprkem'wworkers'coralicy infoimation �porationhas other employees aworkers'compensationpolicy isrequired and such an 2•am an employer that is providingworkers'compensation Insurance CompanyName;ARROWMUTUALINSUinsur�CejOrmyemployees Below rsUtepolicy tnformdiom INSURANCE COMPANY Insurer's Address:23 COMMONWEALTH AVE City/State/zip: CHESTNUT HILL,MA 02467 Policy#or Self-ins.Lk#1821A Attach a copy of the workers'compensat on otic 01/01/20 "4' Ydeclarationpage(showingtheptolicynumberandexpirationdate). Failure to secure coverage as required under Section 25A ofMOL a.152 can lead to the imposition of criminal penalties of a Eno 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 d _� fdoherebycerg verification perjurythat the informationprovided above Istrue and correct ii: erase; awn M. 'hone#.508-394-7778 Date: j '] Official use only. Do not write fir tits area,to be completed by city or town official • • City or Town: Issuing Authority rete one): Permit/L£cense# 1.Board ofHealth 2,Building Department 3.City/Toy,m Clerk 4.Licensing Board 5,Selectmen's Office 6.Other Conta ct Person: phone#: • www.masagov/dia