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Home My WebLink AboutBLDE-19-001439 • °11Commonwealth of Official Use Only Massachusetts Permit No. BLDE-19-001439 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 PRINT IN INK OR TYPE ALL INFORMATION) Date:9/11/2018 City or Town of: YARMOUTH To the Inspector of Wires: By'his application the undersigned gives notice of his or her intention to pertorm the electrical work described below..-_ Location(Street&Number) 164 WEIR RD Owner or Tenant SMITH CAROL B TR Telephone No. Owner's Address MAJOR BABES RLTY TRUST, 164 WEIR RD,YARMOUTH PORT,MA 02675 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 ❑ Undgrd 0 No.of Meters New Service Amps Volts Overhead ❑ 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 13lu- ❑ 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 0 BOND 0 OTHER ❑ (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 (Ifapplicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:8 REARDON CIR,S YARMOUTH MA 026641207 Alt.Tel.No.: Ter 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 uw19.1 K1,5 fg P OfficialU eOnlj Commonwealth oi///a4lae ettl I� Oil ( L 3 9 w Ott cy c7 Per�itO.( ---111 1 ----tint Thepartmant o/Jiro-graces ,_ _ occupancy and Fee Checked : € BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank) • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527/CMR 12.00 (PLEASEPRINT 111MKORTHE ALL INFORMATIO1 Date: a 0/ / 7 City or Town of: /+ Ott To the Inspector of Wires: By this application the undersign' gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) apt/ Vgaz-• 72-0,10 • y yg 0 Owner or Tenant e oL1' i,-rr Telephone No. (D Owner's Address Sig/a / Is this permit in conjunction with a building permit? Yes 0 No �^r (Check Appropriate Box) Purpose of Building ' Q U/t✓,- Utility Authorization No. Existing Service_ Amps • I Volts Overhead 0 Undgrd 0 No.of Meters __• New Service ^ Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity PL Location and Nature of Proposed Electrical Work: ( e(L£dL I . Com.letton o the ollowin:table in, be waived b the Inca ota o Wires. No.of Recessed Luminaires No.of Ceil.-Sus .(Paddle)Fans• o.of p Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators INA Above In- -No.ofEmergency L Opting No.of Luminaires SwimmingPool grad. ❑ grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Ttal Tons No.of Alerting Devices eat'um Number ons » o.ofSel-Contame. No.of p ---- Detection/Alertin Devices rw Totals:/Areunicipal Other No.of Dishwashers Space/Area Heating KW Local❑ Connection security Systems:* No.of Dryers Heating Appliances TCW No.of Devices or Equivalent inNo.of Water No.of No.of Data Wiring: W Heaters KWSigns Ballasts No.of Devices orE uivaient Te ecommuntcatlons ,ring 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [/I� BOND 0 OTHER 0 (Specify:) C\ I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME_ri: ( to 075Loto t. 3 Lo <" fl' r tgg '1 ' LIC.NO.: � Licensee: KtCFFLl2/1 M 2L11 TIO SignatureIK6g ?•�5 • (lfopplicable,enr- "exem.t"in the license n her line.) Bus.Tel.No:�--- Address: - - 4/ /Ot0 tLCt 5tnt ' i Oa t"] 0't ` 0 b 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 am the(check one 0 owner 0 owner's a ent. ' Owner/Agent • PERMIT FEE:$ Signature Telephone No. 1' 1 4 • y4 • • • i ==ate aritiKE AI The Commonwealth of Massachusetts r Department of Industrial Accidents '�� 1 Congress Street,Suite 100 ' "�— • Boston,MA 02114-2017 _,o. wwwmassgov/dia Workers'Compensation Insurance Affidavit:General Businesses.. TOBEFILEDWITH THE PERMITTING AUTHORITY. ArrlicantInformation Please Print Le!ibl • Business/Organization Name:E.F.WINSLOW PLUMBING&HEATING CO.,INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664. phone#:508-394.7778 — Are you an employer?Check the appropriate box: 1.0I am a employer with ry^ Business Type(required): . orpart-time).* t.i.l_employees Mil and/ 5. 0 Retail • 2.0 Iamasole proprietor orpartnershi6. QRestaurantBarIEatingEstablishment • apa i have no ?. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any c 3.❑ 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 4.❑ no employees.No workers'comp.insurance required]** 10'0 Manufacturing We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees.[No workers'comp.insurance req.] 12.0 Other • *Any applicant that checks box 81 must also fill out the section below showing their workers'compensation policy information. **lythe corporate officers have exempted themselves,but the corporation other policy urequired and such an organization should check boxril, ' I am an employer that Is providing workers'compensation insurance for nty employees. Below is the 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.Llc.#1821A Exate: /117 Attach a copy of the workers'compensation policy declaration page(showing the ion ptolicy number01/20and expiration date). Failure to secure coverage as required under Section 25A ofMGL 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.. lith hereby certi I�fj�f� , �� +' �_ Hautes o pessary that the information provided above is true and correct Sip. azure: ...so 0".- Date: ' 'hone#:508-394-7773 Official use only. Do not write in this area,to be completed by city or town official • City or Town: Issuing Authority(circle one): • Permit/License# 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: • www.massgov/dia