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Home My WebLink AboutE-19-3205 I. '4 N Commonwealth of Official Use Only E" !n Massachusetts Permit No. BLDE-19-003205 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.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:11/26/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention t ^rnw the etectrica ork described below. & i7 Location(Street Number) 9 LANSING LN. 1r t b Mg- Owner or Tenant LANSING LANE LLC Telephone No. Owner's Address C/O JONATHAN CHURCHILL, 19 MUSKET DR,ACTON,MA 01720 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 ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Replace panel&wire heat pump system. — - . • . 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 0 Io- 0 No.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 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: IHeaters 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 ❑ BOND ❑ OTHER ❑ (Specify:) f 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 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$50.00 g&J tH, f t' *a Commonwealth o/Maddachudettd Official�j�Use OnI 0'= t ty� c7 Permit No. lam' 1 3 e .CQA, o €m et_ r Theparimertt of ire Serviced `' `---�` d BOARD OF FIRE PREVENTION REGULATIONS Occupancy 1/07and Fee Checked ,� ) (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),52 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFO TION) Date: C/ Z / Cs City or Town of: I.J, zi 6 wt 5r) D To the Ins ecto of Wires: By this application the undersigne9 gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) q L ohosiNG /Ave <SJ Owner or Tenant firC-//4C-//4 & a/D*V//9 Die-Attie. Telephone No. "hip'nay Owner's Address ho SCP7T0,0 Pt- 5auT#,, Mitt-) yof Ny /0027-- Is this permit in conjunction with a building permit? Yes ❑ No a (Check Appropriate Box) Purpose of Building D ry iy6 Utility Authorization No. 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: , t -posetaj&vt- Ff ND -(,)tj6',& fb -70,0 69A/tan -70,0grf (k e/g sys7rms , Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Sus . Paddle Fans No.o Total . P (Paddle) Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires SwimmingPool Above ❑ In- ❑ No.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones oand No.of Switches No.of Gas Burners No. Initiating InitiatinggDetection Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number__Tons_ KW_____ No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Municipal ❑ Other t P Connection O No.of Dryers Heating Appliances KW Security Systems:* ` - No.of Devices or Equivalent v) No.of Water No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or E quiva lent No.hydromassage Bathtubs No.of Motors Total HP Tel N 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.) lb Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. k)0 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 It BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAM gr IJINSLoW P4U,YNI�tP(o d. fli;i�-ria,/� !fix • LIC.NO.: Sly Licensee:(,(C,({{ O M runty Signature v � LIC.NO.:9/82? Lnu (Ifapplicable,entgj exem t�••to the license number line.) V Bus.Tel.No:SGS.3 9I•.777 t� Address: $ /Lt/Y/c-VON CIuiLLtE- 5t411-1 yr4-tMowr+-r, 0119 O>64 Alt.Tel.No.: \ *Per M.C.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. 4 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally bo required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner 0 owner's agent. �. Owner/Agent ��l. Signature Telephone No. PERMIT FEE:$ e The Commonwealth of Massachusetts Qt Department of Industrial Accidents 1 Congress Street,Suite 100 =i!€►= Boston,MA 02114-2017 �� , www mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Business Type(required): • 1.0 I am a employer with 7C) employees(full and/ 5. 0 Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ 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. ❑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]*" 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box#1 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.• I am an employer that is providing workers'compensation insurance for 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.Lic.#1821A Expiration Date:01/0l/20/4 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 the ajhs and p :zanies o perjury that the information provided above is true and correct. Signature: tf ^e.— Date: 1 a I31 112 Phone#:5083944778 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/dia