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Home My WebLink AboutBLDE-18-000739 a Commonwealth of otteialUseOnly f t* Massachusetts Permit No. BLDE-18-000739 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked • JRev.1/07] 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:8/7/2017 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pertorm t etrical work descri ed b tow. Location(Street&Number) 35 OLD CASTLE RD C 094%...3 Owner or Tenant MICKOSEFF TECLA ATR Telephone No. Owner's Address TECLA A MICKOSEFF TRUST,35 OLD CASTLE RD,YARMOUTH PORT,MA 02675 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check App i .8. e Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 Undgrd 0 44,4 New Service Amps Volts Overhead ❑ Undgrd ❑_. Number of Feeders and Ampacity a b O Location and Nature of Proposed Electrical Work: Wiring for air handler and condenser. Y Completion of the following table may be waive• I o}of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of r raj, q/ Transformers f No.of Luminaire Outlets No.of Hot Tubs Generators K A �C No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting grnd. grnd. Rattery 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 Initiating Devices No.of Ranges No.of Air Cond. 1 Total No.of Alerting Devices Tons No.of Waste Disposers Ileat 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 Eauivalent No.of Water KW No.of No.of Data Wiring: Heaters - Stens Ballasts No.of Devices or Eauivalent No.hydromassage Bathtubs No.of Motors Total IIP Telecommunications Wiring: No.of Devices or Eauivalent OTIIER: Attach additional detail ifdesire4 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 ofperjury,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 _ k9 37z1(ie e v 1 s-(2f18i Nit (0( /(6 It o '/ ..^ _ Ufa` �Af� V9 I tai se Ott �\ CammaftalBalih O�/�/al9at(Lad6ttd 739 _�li t c7 Permit No. Il �J v — a apartment 4 lire Serviced Occupancy and Fee Checked s1/4..1;--do BOARD OF FVRE PREVENTION REGULATIONS [Rev.1/07) peaveblank) APPLICATION FOR PERMIT T it PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 12.00 (PLEASE PRINT.1NINK OR SPE ALL INFORMATIOI3 l Date: 0 e rile 7 City or Town of: (i;r to /)-- (IJOf I 1 To the Inspector of Wires: By this application the undersigives notice o his • her into tion tt66 pe j e electrical work described below. Location(Street RiNnmber) _ r - • t , -131 Owner or Tenant i, la OA. • TelephoIlb No. { l ^ Owner's Addressy•33 ' t 1. ' I i JIM 0. 1. la Do Is this permit in conjunction with a building permit? Yes El No ❑ (C eck Appropriate Box) ''`.°j Purpose of Buildingsi 1 I)e 11 t C lQ Utility Authorization No. T).0 Existing Existing Service__ Amps I J Volts Overhead❑ Undgrd❑ .No.of Meters __ New Service _ Amps / Volts Overhead❑ Undgrd❑ No.of Meters ___ --// Number of Feeders and Ampacity �-jj1 Location and Nature of Proposed Electrical Work: Fr r 4C nct i c,rj * CoCn e 13 e r OCompletion of the following table may be waived by the Inspectorof lof Wires. No.of Recessed Luminaires No.oYCei1: No.of Susp.(Paddle)Fans Transformers INA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Abovefn- No.ofl;mergency Lighting No.of Luminaires Swimming Pool grad. ❑ grnd. ❑ Battery Units Nm.of eceptaclf.tlletS.... . _ _ .. NoThronnynirt_ __ __ FIRE ALARMS_INctaflones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cowl. Tonal No.of Alerting Devices No.of Waste Disposers Heat Pump Number Mons ,KW No.of Self-Contained Totals: - Detection/Alerting Devices Municipal Lel No.No.of Dishwashers Space/AreaHeating KW Local❑ Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:*_ No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: t Heaters KW Ballasts No.of Devices or E.uivalent Sr_1 s � e ecommmucations r irrng:No.Hydromassage Bathtubs No.of Motors Total HP 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: 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 (BOND ❑ OTHER 0 (Specify:) I certify,under the pains and penalties of perjury,that the information o ' appli tion is true and complete. FIRMNAME: C P Whilst-ow` � LIC.NO.: 2IfY `�n' Licensee: bail/mei 7if it 4 &, / Signature f/i/ - LIC.NO.:Z/` 0fapplicableyenter"exempt"in the license number line) 7 - Bus.Tel.No. 77,x' Address: b LG., t - ,e Citric S - n.- t /.r ny I - P �y 7 0. 6 Alt.Tel.No.: *Per M.G.L.c.147,s.57-61,security work req ' es Department o Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally I a' required by law. By my signature below,I hereby waive this requirement. I am the(check one CI owner 0 owner's a ent• Owner/AgentPEdtlId7T FEE:$ 60 LI Signature Telephone No.� 4 At 2 c -_ The Corsirraonwealth of Massachusetts 1 a - t Department ofIndustrial Accidents —" • = I Congress Street,Suits 100 ► _ Bosion,hPA02119Z017 • " wwwmassgov/dia : Workers'Compensation Insurance Affidavit:Q,eneral Businesses. TO BE FILED WITH nue PF121tiiTTINGAUTHORITY. . 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#:568-394-7778 Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with 68 employees(full and/ 5. 0 Retail 2.0 or part-time).* 6. ❑Restaurant/Bar/EatingEstablislunent 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 audits 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 requiredr* –4.0 Weareanon-we —}atled6/volunteers, 11:[}Healt care - with noem to ces. . _ _ ._... .. .. . . _. -. p y [No"wotkeis'comp,msuranca req,] 12.0 Other *Any applicant that checks box#1 must alsofill out the section below showing their workers'compensation policy information. **Sithe 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. •I am an employer that is providing workers'compensation insuranceor 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 HELL,MA 02467 • Policy#or Self-ins.Lie.#1821AExpiration 01/01/2017 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 theDIA for insurance coverage verification. • Ida hereby eerti the.a' and?email/es o perjury that the information provided above is true and correct. Big-nature: �, ature: t^ � • • Date: Phone#:508'394-7778 • Official use only. Do not write In this area,to be completed by city or town official CityorTown: PermiULicense Issuing Authority(circle one): 1;Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other ' 1 • I Contact Person: Phone#: