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Home My WebLink AboutBLDE-19-003139 j� \ k Commonwealth of Official Use Only °'• Massachusetts Permit No. BLDE-19-003139 ..—' BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ffev.l/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:11/20/2018 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) 18 CEDAR ST Owner or Tenant MONROE PATRICIA TR Telephone No. Owner's Address THE PATRICIA MONROE FAMILY TRUST, 110 SILVER LEAF LN,WEST YARMOUTH,MA 02673 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 Undgrd ❑ 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: Install generator. 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 1 KVA 11 No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches i No.of Gas Burners 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:* 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: ANDREW M LEVESQUE Licensee: Andrew M Levesque Signature LIC.NO.: 17318 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:461 LOWER COUNTY RD,HARWICH PORT MA 026461831 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 Signaturer /� Telephone No. PERMIT FEE:$50.00 1 c 1 h'e' y /&/.zd�s 1(411 2 � Commonwealth oil ir/aeeachueette Official UseOnlyQ� • -r -'0 d .�i - c� c7 Permit No. Fig e l 3 t • i t= ,4 V weir- T epartment o/T re serviced .�Tit z. Occupancy and Fee Checked y ° ' 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( C),527 CMR 12.00 (PLEASE PRINT IN INK OR_TYPE ALL INFORMATION) Date: 1 ( ( C i12 City or Town of: Y��Of* - To the Insp ctor of Wires: By this application The undersigned gives 1 otice of his or her intention to perform the electrical work described below. Location(Street&Number) 1 ,/v[ c I S I '! St I't Owner or Tenant _ 41 Teleph i ii a No. Owner's Address - Is this permit fin conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building YY'(2�1P)4 i "(,g Utility Authorization No. Existing Service Amps / Volts Overhead 0 Undgrd❑ 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 Completion of the followinatable may be waived by the Inspector of Wires. oof Total No.of Recessed Luminaires . No.of Cel:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting • grad. grad. Battery Units No.of Receptacle Outlets No.of Oil Burners . FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detectionand Initiating Devices • Tota No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: • Detection/AlertingDevices No.of Dishwashers Space/Area Heating KW Local 0 Municnnectiipalon ❑ Other Co Security No.of Dryers Heating Appliances KW Noof 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 Tel No.of Devicuivans lent No OTHER: • `� Attach additional detail ifdesire4 or as required by the Inspector of Wires. Estimated Value of Electrical Work: � V 7 0 - (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 Er BOND 0 OTHER 0 (Specify:) • I certify,under the pains and penalties of perjury,that the information bn this application is true and complete. • NRM NAME: `f.1-11AV IGt-F FORT I1ga71 N tWO LI N W.0 LIc.No.: 3� cfrile Licensee: IT IV � ( f/ Signature / .�^ wvd� LIC.NO.: -A tj ' , (If applicable.enter "exempt"in the license number IiI. , / Bus:Tel.No.. g5 A: Cr Address: IO 1 1/01V-Mg– couN Til/( • I it. /W t ft'WM/1( t (� T Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Sa ety"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 PERMIT FEE: $ 5 0 Signature • I Tele qne No. KeGiACO kPHc, IG . COM an gall The Commonwealth of Massachusetts „Fit 1.. Department of Industrial Accidents 4� d',; +F , f Office of Investigations ; :a 1VT +c 600 Washington Street t.= uxs='a:7; Boston,MA 02111 k.'CE, fi't v 5i-: www.tnass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information - Please Print Legibly • Name (Business/Organbation/Individual): Harwich Port Heating&Cooling LLC Address: 461 Lower County Road t City/State/Zip: Harwich Port MA 02646 Phone/k 508-432-3959 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 75 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub contractors 6. ®New construction 2.❑ I 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. employees and have workers' y 12 Building addition [No workers' comp. insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.12 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.1-2 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required]t c. 152, §1(4),and we have no employees. [No workers' 13.1;3 Other HVAC comp.insurance required.] t *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Selective Insurance Company of South Carolina Policy#or Self-ins.Lic./#:, •WC9059813 Expiration Date: 10/'2,6//22019 /�J�� ,I�f� Job Site Address: I g & AaA City/State/Zip: S(/Vlf Y1 w W4wV t i I vgi Attach a copy of the workers' compensation policy declaration page(showing the policy number and exration 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. , (do hereby certify under e •+a ins andp allies of perjury that the information provided above is true and correct Signature: II i f Date: I (I is"12 ?hone#: 508-432-3959 Official use only. Do not write ht 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: - Phone#: