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Home My WebLink AboutBLDE-19-003499 a r Commonwealth of Official Use Only � Massachusetts Permit No. BLDE-19-003499 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked IRev.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 ININK OR TYPE ALL INFORMATION) Date:12/10/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pertonn the electrical work described below. Location(Street&Number) 300 BUCK ISLAND RD UNIT 10 Owner or Tenant ROLLAS DEMETRIOS Telephone No. Owner's Address 300 BUCK ISLAND RD UNIT 1 B,WEST YARMOUTH, MA 02673 Is this permit in conjunction with a building permit? Yes 0 No ❑ (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: Replacement furnace.(UNIT 1-B) 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- 1:1No.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/Alertine 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 Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Siens 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 ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $50.00 ctta (7142 (( n ' Commonwealth of rrlassakeetie 02:90 O�y3 \�C G� " --e---4r-r-M cy, c7 Permit No, 1 •,I I' 1Jeiaarfinenf o�.}lre services 'Mr. BOARD OF FIRE PREVENTION REGULATIONS [Rev.1107]( leaveb an and Fee Checked • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordancewiththeMassachusetts Electrical Coda(1/39,k7 527 CMS 12.00 (PLEASEPRINTWINK ORTUE ALL EVORMATION Date: II/ ti / /4 City or Town of: `(OtlMQ r (,, To the Inspector of Wires: By this application the undersigned,gives notice of his or her intentio-to perform the electrical work described below. , Lb'cation(Street&Number) Q t ; Is IQ P 1 4 ea rI S , . - 12673 Owner or Tenant acpr'w '14/141-5 Telephone No•5 $l4 152t Owner's Address �;WINS_ Is this permit in conjunction with a building permit? Yes 0 No C (Check Appropriate Boa) Purposeot13ullding bwvlhnai Utility AnthorizationNo. Existing Service Amps ' / Volts Overhead❑ Undgrd❑ No.of Meters __ • New Service _ Amps / Volts Overhead Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: F •t . . ,'b., A I / hien • • . addle Cam.letiano the ollowin:tablen' bewaived b the Ins tTctoro Wires. a No.of Recessed Luminaires No.ofCeil:Sus of • P )Pans Traa onsformers RVA No.of Luminaire Outlets No.of Hot Tubs Generators TWA. No.of LuminairesAbove In- 'No.ofEmergency Lighting Swimming Pool , d, ❑ : nd. ❑ Batter Units No,of Receptacle Outlets. No.of Oil BurSers FIRE ALARMS No.of Zones — • No.of Switches No.of Gas Burners No.of Detection evlceic Tn tiat ngDs No.of Ranges No.of Air Cowl. Total Tons No.of Alerting Devices No.of Waste Disposers Heat-Pump Number Tons IOW No.of Self-Contahgd Totals: ,,Detectlon(AlertinPa Devices Ma No.of Dishwashers Space/Area Heating KW Local❑ Connecunicitpion Ill Other No.of Dryers Heating Appilances �ecN.ofDavices No.of DevicesorE uivalent o,of ti ater ICW o.o D.of Data Heaters Signs Ballasts No.of Devices Or E uivalent No.HydromassageBathtubs No.of Motors Total HPNo.of Devices or E uivalent o • 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. H CHECK ONE: INSURANCE Er BOND 0 OTHER 0 (Specify:) I cert,under the pains and penalties of perjury,that the Information on this application IS true and complete. (v O.0 FIRMNAn: c to NnS/vw •� . -- . h s t- ?r 4 ' LIC.NO,: _�j' `tom Gln Licensee: ICfFF((L/Z/�gL(J(IfI Signature �J .J LIC.NO.:oO—S2g (Ifappltcable,ent�•"exem.t"Inthe license=fiber lint) Bus.Tel.No.•�/38 � N Address: " .L' 1 JON e Int t.( die o cf 0 4 Alt TeLNo.: IwIrawaict of Public Safety"V'License: Lk.No. S VOW ER'SINSURANCEWAIVER: amawarethattes henseedoesnothetheliabilityinsmrencecoveragenom: y .required by law. By my signature below,I hereby waive this requirement, I am the(check one)❑owner 0 owner's agent Owner/Agent Signature Telephone No. I PERMITFEE: $ . t t-�?M �t The Commonwealth ofMassacliuyetis iv pr Department of lndustrtalAcoklents t�=11�= .1 Congress Street,Suite 100 , , • Boston,MA 02114-2017 • Workers' wwWmassgov/dia Compensation Insurance Affidavit:General Businesses.. TO BE Fan yrM.HT�p GAUTEORITY, A s s lieant Information Please Print Le.ibi • Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO.,INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664. phone#:608-394-7778 Are you an employer?Check the appropriate box: 1.B Iamaemployer with 1�employees and/ 5. ❑Retail Retail siness . or part-time).* 2.0 I am a sole proprietor or partnershi p and have 6. ORestam'ant Bar/Bat ng Establishment • employees wor ' no • kmg forme in any capacity. 7. 0 Office and/or Sales(incl.real estate,auto,etc.) 3.0 [No workers'comp.insurance required] We are a corporation and its officers have exercised 8. 0 Non-profit • their right of exemption per c.152, 14e9. DMnuacment no employees.[No workers'comp. i ( rd eq have 10.[]manufacturing ng 4.0 We are a non-profit organization,s insurance requrred]++ with no employees.[No workers'commsp. nsurance volunteers, 11.0 Health Cara *Any applicant that checks box 41 must also Ell out the secdon 12.[]OtheT 'If the coryomfe officers have tion below showingtheuvmrkers'co organization should check boxp nP areouelves,but the corpomtioahas otheremployees,arnpensationpolicy information. workers'compensation policy is required and such an 1.r `"_--%4't0yer'ritatirprovtdrngworkers c°mpensation--- InsuranceCom an ARROW MUTUAL NURANCsurancefornryemployees Below istl:epoltcyinjormation Company INSURANCE COMPANY Insurer's Address;23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL,MA 02467 • Policy#or Self-ins.Lk.#1821A Expirationate: Itp Attach a copy of the workers'compensation policy declarationpage(showingth policynumber01/2andexp ation date). Failure to secure coverage as required under Section 25A ofMGL 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 afire 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 cera , , • ' ;,enalttes o perjury that the information provided above is true and correct Sicnature• p L «�„_, 1 7 'r one;•508.394.7778 Date . Oficial use only.Do not write in this area,to be completed by Mfy ortown official • City or Town: . Issuing Authority Permit/License# . I.BoardofHealtir(2 BuildingDe): • • 6.Other Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office Contact Person: Phone#: www.massgovidle