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HomeMy WebLinkAboutE-18-2627 Commonwealth of Official Use Only , E ,►:1 Massachusetts Permit No. BLDE-18-002627 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:11/2/2017 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 26 HOLLY LN Owner or Tenant ODONNELL WILLIAM J Telephone No.CN ts Owner's Address ODONNELL CATHERINE A, 17 KENSINGTON DR, BILLERICA,MA 01821-3057 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Ch 1161. .rop.:, Purpose of Building Utility Authorization No. 1 0 Existing Service Amps Volts Overhead 0 Undgrd 0 11/4.4641111o.4%.,rs AA New Service Amps Volts Overhead 0 Undgrd 0 No. 4Q' I''/� Number of Feeders and Ampacity %/ `/ /Vj/, Location and Nature of Proposed Electrical Work: Replacement furnace and add CO detector. 2 de Completion of the following table may e wttZ by t ,A .r of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of otal Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Rrnd e 0 grid. o No.of Battery mergsency Lighting 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 1 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 Eauivalent No.of Watery No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Eauivalent No.Hydromassage Bathtubs No.of Motors Total lIP Telecommunications Wiring: No.of Devices or Eauivalent 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 Metvin 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 ant 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 neTelephone No. PERMIT FEE: $50.00 tJ//n I/1/�8 let 4A ( sp ._ -72)/e I e a 4104<e • % ,/ - C/� 6e� rql////qq / Official se Only omnwnwea[th o rrla3eachuaeffd • .t cc77 C� Permit No. 0 -- ..2...2.5 sla Fd vccyy�UePartmeni'otJira Serviced Occupancy and Fee Checked t'll e4» 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 CMIt/,1/2.00 (PLEASE PRINT IN INK OR TYPE ALL INF RMAJIOM ) Date: I C) /a7/ 17 City or Town of: (;(r pi6u Snf 5J To the Inspector of Wires: ' By this application the undersi d gives notic o his of er intenti.nperform the electrical work described below. Location(Street&Nu • .er) ��p © n �/tt:5�i%Y _a r�R Owner or Tenant • • • • e I ► 1 Telephone No. C•lfi%G 3 V Owner's Address 17 Clps, 1 I • C I l/P J . t () ruin , .0rZa W Is this permit in conjunction with a bu+ldmfr permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building NO e A 1 1 (> Utility Authorization No. Existing Service_ Amps / -Jolts Overhead❑ Undgrd❑ No.of Meters __ New Service _ Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location an. atur:of Proposed lectrical Work: ta: eQ S - V , it Ot , ,• t• • , go • `o.'tion o the ollowin: table mu be waived b the Ins.•ctor o Wires. t r.o otal No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.of Emergency Lighting No.of Luminaires Swimming Pool grnd. 0 grnd. 0 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 Total No.of Alerting Devices No.of Ranges No.of Air Cond. Tons Heat Pumpber.fons.,_,.I`KW __ No.of Self-Contained No.of Waste Disposers Totals:INum [fon! Detection/Alertin Devices cipio 0 Other No.of Dishwashers Space/Area Heating KW Local 0 Connuniection HeatingAppliancesKW 'Security Systems:* V) n No.of Dryers No.of Devices or Equivalent DC`! I No.of Water No:of Ni.of Data Wiring: HeatersKW Signs Ballasts No.of Devices or Equivalent 1� Telecommunications Wiring 1. — No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent I 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 coveragea { is in force,and has exhibited proof of same to the permit issuing office. tv� 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: 'KF cDjO6LOW pt.ttri3tPts 8. (+e�" � LI (� i10= • LIC.NO,: 3, `o' M(L -3763.!6-- Licensee:CR(Cfn M t2 VIN Signature /I SLG, C.No.:9l57,2`T� (If applicable,encsr"exempt"in the license number line) t/ j Bus.Tel.No.:508.3 9 •'77 ' Address: JL2.4 -DOP CuU2t `JUttfi-I f1frtnioltrt-}i eke 07-4 Alt.Tel.No.: *Per M.G.L.c.147,s.57-61,security work requires Department of Public Safety"5"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 art Owner/Agent I PERMIT FEE: $ SO , U Signature Telephone No. 094,/ • The Commonwealth of Massachusetts t -fit= l Department of Industrial Accidents =aerl1 Congress Street,Suite 100 =' - Boston,MA 02114-2017 r�f=Ira www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664. Phone 11:508-3947778 - Are you an employer?Check the appropriate box: Business Type(required): 1.❑✓ I am a employer with 10 employees(full and/ 5. 0 Retail 2.❑ or part-time).* 6. ❑Restaurant/Bar/EatingEstablishment I am a sole proprietor or partnership and have no 7• El 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.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c.152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required?* 4.❑ We are a non-profit organization,staffed by volunteers, I1.❑Health Care with no employees.[No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information. • If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. lam an employer that is providiiag workers'compensation insurance or rnP f 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.Lie.#1821A Expiration Date:01/01/201g Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL 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. I do hereby certi r theSts and enalties o perjury that the information provided above is true and correct Signature: • i5'/t/` +w i Date: i a- /31 //8 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#: www.mass.gov/die