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Home My WebLink AboutBLDE-19-003978Commonwealth of Official Use Only ®Massachusetts Permit No. 13LDE-19-003978 �--' BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked Rev.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 INFORIIIATION) Date: 117/2019 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice ot his or her intention to per orm the electrical work described below. Location (Street & Number) 89 SOUTH SEA AVE OwnerorTenant DREW RICHARD HJR Telephone No. Owner's Address DREW NANCY LOUISE, 89 SOUTH SEA AVE, WEST YARMOUTH, MA 02673 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building 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: Replacement furnace. 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- [3No. gr d. grnd. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners 1 No. of Detection and Initiatine Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump' Totals: umber Tons KW No. of Self -Contained Detecflon/Alerfin2 Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other: Connection No. of Dryers Heating Appliances KW Security Systems:• No. of Devices or E uivalent No. of Water KW Heaters No. of No. of Isigns Ballasts Data Wiring: I No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: o. of Devices or E uivalent 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:) 7 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 linea 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. l am the (check one) ❑ owner ❑ owner's agent. Owner/Aeent Signature Telephone No. ottp 1118,6(4 ,e� PERMIT FEE: $50.00 ", •.:.'. 6mmonwea(!h o` rr/adsachweth I Use Oly 1eParlmant oltire Serviced Permit No. 9 — Q O OccuBOARD OF FIRE PREVENTION REGULATIONS [Rev 1/07j (eeecked aveblahn tA. APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALLINFORMATION) Date: /� �s1�a City or Town of: rd Clv�5r� To the Inspector of Wires: By this application the undersign d gives notice of his or her intention to perform the electrical work described below. \ Location (Street & Number);r,7 :�?Panl/ t, -OO Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No [a� (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service _ Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:Fmlceym� PLyf�hr�� Completion ofthe followin¢ table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Paddle Cell: Sus . p (Paddle) Fans o. o ota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires n - Swimming Pool rnd. ove Elrnd. ❑ o. omergency ging Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. o etection an Initiating Devices No. of Ranges No. of Air Cond. . foo$ No. of Alerting Devices No. of Waste Disposers p eat um Totals um er ___._ ""' Tons ! —� o. oSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ municipal Connection❑Other No. of Dryers Heating Appliances KW ecunty ystems: No. of Devices or Equivalent No. o aterKW o. o o. o Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent No. hydromassage Bathtubs No. of Motors Total IIP r tang: a No. of Devices omm Devices Nor E uivalent OTHER: Attach additional detail ifdesired, 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 t BOND ❑ OTHER ❑ (Specify:) I certify, under the pales and penal[les ojperjury, that the [nforma[lon on this application is true and complete. FIRM NAME: [fJ IJSLpW a LIC. NO.: 1 L Licensee: jr'/�([,Fi' l) M `1-LWIi) Signature NO-918;t'JIV (Ifopplicable, ent "exempt' !n the license number line.) Bus. Tel. No.-&-- I fC2A DON Grftae 50utri q"-Mout>�t v>TH OY�Io AIt.TeLNo.: •Per M.G.L. c. 147, s. 57-61, security worn requires Department of Public Safety "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, l hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ A .. 1 The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 If www massgov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leiibly Business/Organization Name: E. F. WINSLOW PLUMBING & HEATING CO., INC 8 REARDON CIRCLE City/State/Zip: SOUTH YARMOUTH, MA 02664 Phone #: 508-3947778 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑Z I am a employer with 10 employees (full and/ 5. ❑ Retail or part-time).* 6.❑RestaurantBar/EatingEstablishment 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. S. ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10 [1 Manufacturing no employees. [No workers' comp. insurance required]* 4. F-1Weare a non-profit organization, staffed by volunteers , 11.❑Health Care 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. ••Ifthe corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box # L. 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: 01/01/20(i - 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 508-394-7778 the Information provided above is true and correct Offlcial 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 #: