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Home My WebLink AboutBLDE-19-000535 • Commonwealth of Official Use Only or AMU Massachusetts Permit No. BLDE-19-000535 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked (Rev.I/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:7/26/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice bthis or her intention to perform the electrical work described below. Location(Street&Number) 47 BAYBERRY RD Owner or Tenant PREUS PAUL G LIFE EST - Telephone No. Owner's Address PREUS CHRISTIAN P&NICHOLAS E,3126 SPRINGWATER RD,DECORAH, IA 52101-7408 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 100 Amps Volts Overhead ❑ Undgrd ❑ No.of Meters New Service 100 Amps Volts Overhead TO Undgrd 13 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Upgrade service. 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 13l r E:1No.of Emergency Lighting grnd. gnd. 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 Initiatine 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/Alertine 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 Siete; 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 (if applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:8 REARDON CR 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) ❑ owner 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$50.00 1\1714— to lcfIt6 lee mirth - g Official Use Onlyyy ��— Commonwealf o�///aesachu�¢tf� aq^ ? 5 f a 1 7 r_51I'e ft Thepartment Serviced t No. ,� (lie: . .Department o/Sire Serviced Occupancy and Fee Checked • f''‘,7,79 BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank) • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK ORME ALL INFORMATION) Date: 1 I?a) City or Town of: Yaf iVlnyfk To the Inspector o Wires: By this application the undersigned gives notice of his or her inteu ion to p rfonn the electrical work described below. Location(Street&Number) L^l new ( �C, Owner or Tenant Chr S `pre us - �� OCti Telephone No. 21Oth0$S---) - Owner's Address \`li)S 1 LoAce 1 .0 C t- Is this permit in conjunction w' h,a building pert? Yes ❑ No (Check Appropriate Box) Purpose of Building OW QY1,n. Utility Authorization No. • Existing Service no Amps /2 /Zito Volts Overhead Kt Undgrd❑ No.of Meters New Service /60 Amps /2a I Z r/OVolts Overhead® Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:Nat) Qt ettrt},t.!Cad) 5oG✓/e.e Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Sus . Paddle Fans No.of Total P (Paddle) Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators IC A No.of Luminaires SwimmingPool Above ❑ In- ❑ No.ofimergency Lighting grad. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones and No.of Switches No.of Gas Burners No. DetectionIn InitiatinggDevices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump'Number Fons�KW No.of Self-Contained Totals: I - Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Municipal ❑ Other P Connection HeatingAppliances KW 'Security Systems:* No.of Dryers pPNo.of Devices or Equivalent No.of Water No.of No.of Data Wiring: theaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications ofDeiiceso or qu v l No.of Devices 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 ca ! o-�verage is in force,and has exhibited proof of same to the permit issuing office. V CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. J O FIRM NA�"�, I ( 01061.4 Pt ltry73tN(n e. fte4- r - '7 • LIC.NO.: `$ic z' Licensee: sr ` I4ICtfA2.Q fit?who Signature / "40. LIC.NO.k /5771 ' ' (Ifapplicable_ent- 'exem.t"inthe license number line..) Bus.Tel.No.•568.3igent" M Address: ; i1L/0N eat V V Idr iit I-1 !At O bfv1. Alt.Tel.No.: tp ( (fl *Per M.G.L.c. 147,s.57-61,security wor requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally ID required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner 0 owner's agent. ili Owner/Agent PERMIT FEE: $ Signature Telephone No. 4) /tic • 0 Aso '.vnsuWI/rf a &s. J Ars.wusousuo.w +' Department of Industrial Accidents ==== N` tt =E/ Office of Investigations 600 Washington Street ' =Vi! Boston,MA 02111 � .'. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information r 1 Please(� Print Legibly Name(Business/Organization/Individual): e.c.wr.15�Oh,.t OU.•An�wtct d a. �to_3/4- . `e.} J:nC. Address: ' Keoctt:✓1 C c1Q� a City/State/Zip: Sou Son rcY'0"0,14, NPc Phone#: `5tN- 399-17751 Are you an employer?Check the appropriate box: Type of project(required): Xam a employer with 70 4. 0 I am a general contractor and I 6. 0 New construction , employees(full and/or part-time).* have hired the sub-contractors :.0 1 am a sole proprietor or partner- listed on the attached sheet._ 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. 0 We are a corporation and its - required.] officers have exercised their 10.0 Electrical repairs or additions :.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp. insurance required.] thy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing ell work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. ant an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. /� 1 isurance Company Name: /TY{'p ..i rr�� Ue.A `t inhcrfanc Capesit li olicy#or Self-ins.Lie.#: 1$a I Ac • '1 Expiration Date: —] - aOi9 tb Site Address:23 Cw Anty cin k.01-€0-141-1 )crl•Q� CFeg gill City/State/Zip: Oar-110 7 ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a da a:ainst the violator. Be advised t t a copy of this statement may be forwarded to the Office of tvestigations • the DIA for insura.- overage veil a on. do hereby certify un • le sins a /penalties o p jury that the information provided above is true and correct. Date: [ail 1 1 am hone#: 3119. 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.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: • Phone#: