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Home My WebLink AboutBLDE-19-001528 �.. [2f Official Use Only y co Commonwealth of aL IIrt\\ Massachusetts Permit No. BLDE-19-001528 iso`T�Er7 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked (Rev.l/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 ALLINFORMATION) Date:9/13/2018 City or Town of: YARMOUTH To the Inspector of Wires. 7/r-- I ,.,~ff^_ ��7 By this application the undersigned gives no ice o is or cr in en ion .per orm e e ec w. describe bel %'''S7 Location(Street&Number) 21 WILDFLOWER VILLAGE i k it t E C Ss Owner or Tenant GRAHAM MILTON R TRS Telephone No. • Owner's Address GRAHAM GERTRUDE J TRS,21 WILDFLOWER,YARMOUTH PORT,MA 02675-1474 Is this permit in conjunction with a building permit? Yes ❑ 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 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Replacement HVAC 8 add CO detector. 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- CINo.of Emergency Lighting grnd. grnd. Batten,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. 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 0 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 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 tk I 7 A alate Ve l7Y/j- 12/c/ie re--1 Commonwealth 0/M b11acL Qis Official Use Only r� �� p Permit No. annl nn k � apartmentol. ire. ervicesz Occupancy and Fee Checked"z.�sp 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(ME ),527�j 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFO TI 1 Date: Oct ,I() 1 [ City or Town of: yoo-D1 "1- 1 To the Inspector of Wires: _ By this application the undersign gives gives notice 6 hi or. rtention ttt333 perform electrical work described below. UQ Location(Street&Nu. .er) .1 •a . ' ■ �/� ' _ Owner or Tenant a. Ar� •�yF�%b �Iu�u,�ss�� - t3 Owner's Address ]r V • Jtllrlrw%lillialg V ► i 'ir, • l0 r Is this permit In conjunction with building permit? Yes is No El (Check Appropriate Box) 0 Purpose of Building j (�q Utility Authorization No. Existing Service= Amps __ / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity —,��.� ! Location and afore ofeciof proposed Electrical Work: . 1' i��71i IIIPBM• 01 `]- .. - A • Cont letfon o the ollowin:table ma be waived b the Ins sector o Wires. T o.oota No.of Recessed Luminaires No.of Ceil.-Sus . addle p (PaddleFans Transformers KVA • No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- -No.ofhmergency Lighting No.of Luminaires Swimming Pool grnd. 0 grad. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection anrr No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Tans No.of Alerting Devices Heat Pump Number Tons KW No.of Self Contained Totals: Detection/Alerting Devi No.of Waste Disposers ces M No.of Dishwashers Space/Area Heating KWLocal❑ Connection l 0 Other Heatin Lances gW ecurity Systems:" No.of Dryers g APP No.of Devices or Equivalent No.of Water KW No. No.of Data Wiring: Heaters Si:,s Ballasts No.of Devices or E.uivalent e ecommunications irm No.Hydromassage Bathtubs No.of Motors Total IIP 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 Fi BOND ❑ OTHER ❑ (Specify:) • I cart,under the pains and penalties of perjury,that the information on this application is true and complete. FIRMNA . 051-00 Pt-CC.1/30UIp a- fig*- r Co. /P C . LIC.NO,: .j'2` 4L !/ Licensee: 6GF�'R2M`Lt Q Wty Signature Li # ' LIC.NO.k9Ign • (ifapplicable,entr"exam st"In the license nuytherline.) I Bus.Tel.No.L40,3'i4/g Address: " L 'g tent) (Lae 5vlt hie M.tt Hoot 0 . 4 Alt.Tel.No.: *Per M.O.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 required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner 0 owner's agent. Owner/Agent • I PERMIT FEE:$ ,57 OI (it Al Signature Telephone No. 41 i • The Commonwealth of Massachu,setts tg_1jih(t Department oflndustrialAccidents �.-1iia= 1 Congress Street,Suite 100 • Boston,MA 02114-2017 '' wwwmassgov/dia Workers'Compensation Insurance Affidavit:General Businesses.. TO BE FILED WITH TBE PERMITTING AUTHORITY. Applicant Information Please Print Leeiblt 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: Business Type(required): I.[]✓ I am a employer with IQ_employees(full and/ 5. 0 Retail or part-time).* 6. 0 RestaurantBar/Eating Establishment • 2.0 I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. 0 Non-profit 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment • their right of exemption per c.152,§I(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]** 4.0 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 thatchecks box NI must also fill outthe section below showing their workers'compensation policy information. **lithe corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box NI. I am an employer that is providing workers'compensation insurance for my 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.Lic.#1821A 01/01/20q' ExirationAttach a copy of the workers'compensation policy declaration page(showing the pol cy number and expiration date). 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certi :.• the,a• and Penalties o perjury that the information provided above is true and correct Signature; p ., Date: /3 / /r7 l� 5 • phone#:508-394-7778 • 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: wwwmass.gov/dia