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HomeMy WebLinkAboutBLDE-19-003174 Commonwealth of %,..., Official Use Only L. k� Massachusetts Permit No. BLDE-19-003174 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' (PLEA SE PRINT IN INK OR TYPE ALL INFORMATION) Date:11/21/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of has or her intention to pertonn the electrical work described below. Q / f -�4/-� Location(Street&Number) 5 WALTHAM CIR RI 4 J Owner or Tenant MANSFIELD CHRISTINA H Telephone No. Owner's Address MULAK ERIC S,5 WALTHAM CIRCLE,WEST YARMOUTH, MA 02673 Is this permit in conjunction with a building permit? Yes El 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 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 ❑ In- 13No.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 ❑ Other: Connection No.of Dryers Heating Appliances KW Security Systems:"' 'i 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 (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) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$50.00 ' Occupancy and Fee eo ________, , . • BOARD OF FIRE PREVENTION REGULATIONS [Rev 1/071 peaveblaoic) r �Jl� —3\"l L` �` APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK �J� All mkt)beperformed Inaccordance with thelviassachusettsElectrical Codl(MEC),52 CM 12.00 (PLEASEPPJNTIN INK ORT�P,EJILLINFORMAT10N) Aate: 1� • City or Town of: ftfmtfU1-k To the Inspector of Wires: • By this application the undersigned;Hires notice of his or her intention to p erfonsthe electrical work described below. L'scation(Street&Number) i LAIn ' It on, .. 07"1 Owner or Tenant Eric, MV A k TelephoneNo. HY31_ $ Owner's Address a, m Z Is thispermitinconjunctionwithabuildingpermt? Yes ❑ No C (Check Appropriate B or) VurposeoIBullding ' Tyw4'IV.'A& Utility Authorization No._____________- Brisling Service ^ Amps I volts Overhead 0 Undgrd❑ No.of Meters New Service _ Amps a Volts Overhead Undgrd❑ No.of Meters ,__ Number ofFeeders and Ampacity Location and Nature of Proposed Electrical Work: I i • 1 'I id • r r o Wires Coin:Teflon o the ilowin table o be weiveuu t 'sic of Iota No.of Recessed Luminaires No.oZCeil,-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No,of Hot Tubs Generators 0.0 mer enc)' g g No,of Luminaires SwimmingPool rade ❑ :id. ❑ Bette Units No.of Receptacle Outlets. No,of O lBurners BidALARMS — o,of etec on an • No.ofSwtches No,of Gas Burners Inittatin Devices No.of Ranges No,of Air Cond. oa No.of Alerting Devices Tons eat um umber ons o.of e 1- ontaine Totals: No.of Waste Disposers P _.__•--•--•'' ----•- Detection/Aladin,.Devices uncia (] Oy • No.of Dishwashers Space/AreaBeating KW Local[] Connection 21 ecurity stems: No.of Dryers Heating Appliances ICW No.of evicesorE Bivalent o.o V ater o,o o.o Data Wiring: Heaters KWSi s Ballasts No.of Devices orE uivalent e ecommunica ions ir'ingg: • flo.IIydromassegeBathtubs No.Of Motors Tota1HP No.of Devices orE ivalent Attach additional detail ifdesired or as required by the Inspector of Wires. Estimated Value of Electrical Work: Prequested(When required by municipal policy.) P completion. Work to Start: InspectionsinaccordancewithMECRule10,ando on 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 exhibitedproof of same to the per it issuing office, C� CKOlE: INSURANCEEll BOND 0 OTHER ❑ (Specify:) ltcattonislrueandcamplete • • • I cerah,under theepains and penalties of perjury,that the Information on this app . LIC.Np,e dm FIRM NAME: C it.) WiptJ a/a , d" t'' r I r . LW.NO.:_,3 e� Licensee:"g,jafL�() M2WM) Signature I 6 g Com. Bus.Tel.No.' (If applicable,,eatr.esm•0"hitheltcensenarrderltne.) t� Address: L'.4/ I4/� gat SUfE ;tr lj I(t ph ` 0 ,y�Am TeL No.:..------ -- o.:_— ' *Per M.O.L.o.147,s.57-61,securitywor requires Department of Public Safety"5"License: Lb .No. _________ OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverageenorm gent cc — Yequired by law.By my signature below,I hereby waive this requirement. I ern the(check one)❑o�0 o Owner/Agent p$RlbflfFEE:$ SignatureTelephone No,_______ . • t The Commonwealth • Y2 1l Depar noof trlat. saclit • nts • �?m"s `� pt 1 Congress Ste Suite100eafs „y Boston,d24 02114-2017 www.mass.gov/dta Workers'Compensation TO BE i¢suranceAf$davif:0eneral$usnesses. e.licant7ttformatiott BTLEDWIT$ T TBEPER5 iTINGADTgORITY. Please Print Ler 3>asiness/Orgatilzation Name:E.F.WINSLOW PLUMBING1.1 lddress:8 REARDON CIRCLE &HEATING CO„INC ity/State/Zip;SOUTH YARMOUTH,MA 02664, e you an employer?Check the a Phone#;608394.7778 1aa amployerewith Check ppropriatebox: I am a time).* ��employees Business Type(requ red); lamasola (fen 5. �Itetai • Proprietor or partnership mid have no 6. QRestamant/Baz/Ea' • employees working forme!natty 7• ❑ h((incl. rebl Establishment [No workers'comp.insurance required] Office and/or Sales(ncl.real estate, We are a corporation and its oauto,etc.) . We tofexem grcershaveexercised S' Cr❑Non-profit exemption per c.152,§I(4),and We have ❑Ente • no employees. 9' eta nment [Noworkers'comp.insurance required? 10.0 Manufacturing ] We are a non-profit organization,staged by volunteers Il.�—t • with no employees.[No workers'comp. �!Health Care pvli�amat Heel • • s equate oa` se 'mnstakofill outthesecGoq insurance 12.p Other ' 4anon,plisfioWd checks bocil exempted out sbutation wshowinatbeirwadiers' \ e corporation has Otter oa.wpckers'compensation mpensationPation. P ' employees,aworkers'coIDpc�etlmpolicyyraryiredand,aeh en ox#1. utemp>oyv.t)�Ct' rovldingwarkers co ncaCompanyName:gRROWMUTUAL INSURANCECOCeforntYernpt°Yeec' Belowlst&epoltcylnformatton ' is Address:23 COMMONWEALTH AVE COMPANY . ateJZip; CHESTNUT HILL,MA 02467 • Not'Self-ios•Lie.#1821A a copy of the workers'compenationPokeydeclaratio gthep licDate:berandexpiration to secure coverage as required under Section tt $ecure.co coverage as on25AofUOL .152ccanleid oiteeimpyn¢mbe and alpratio es of • b$1,50adayd/oronthearimprisonmentaswellascivil nalcanleadtfUrofaSTOnof WR nal ) attonsof the DIA for 00adayagainsnsur Be advised that aco 'PethisstsemetmaybfaSTOPWORICORD Uesa ancecoveragever PYofthisstatementm liRandafirta tbycertta cation aybeforwardedtotha0ffaof ntlo prr ytltatihetformlonproviddbtrueandcarreat �a� sob-394.7778 3 Date: a7 taseonl; / Y Doxotwritetnlhts _ • area,to beconvicted by�yorf Town: own offlctaZ ' A¢thortt3(circieone): Permif/Itcense# 3 ofHealUt 2.BuUdin t gDepathnent 3.Clty/fioym QerJr 4.LtcensingBoard 5.Selectmen's Office Person: ' • Phone#: wa'a'"massgov/da . 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