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Home My WebLink AboutBLDE-19-006517 Commonwealth of Official Use Only Massachusetts Permit No. BLDE-19-006517 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 INFORMATION) Date•5/17/2019 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pertorm the electrical,work described below.6 Location(Street&Number) 9 SCRIMSHAW LN 'B«-L.- 1 vR-i0 Owner or Tenant SRl BOO-RS Telephone No. Owner's Address , 9 SCRIMSHAW 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 0 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: Air Cond. 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- ❑ 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. 1 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 ❑ (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 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$50.00 � � 74/1 0, J(��. 1� Official Use Only • (2oranlAnWea ,Z or maodac uoetf Cl / _y r °Uepartin it o/. ire seruice5 . r Occupancy and Fee Checked__________ „ ) BOARD OF FIRE PREVENTION REGULATIONS [Rev U07] (Ieayeblank) APPLICATION FSR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),527 2.00 (PLEASE PRINT.ININKORT EAL.LINFO TIO Date:� City or Town of: ) i)je �7) To the Inspector of Tres: By this application the undersign gives notice of his or her intention to perfor the electrical work described below. . Location(Street&Number ` e (',+ r,r)c'r)e,/,,c) . p • ' (() Owner or Tenant ) elephone No, / L �.,�� (j/) Owner's Address ' • `x Is this permit in conjunction with a building permit? i 'yes ❑ No (Chec)!C Appropriate Box) � ., Purpose okBuilding.D L C-j I i r) Utility Authorization No. t'� Existing Service Amps I J Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps _ / Volts Overhead= Undgrd E No.of Meters Number of Feeders and Amp acity Location and Nature of Proposed Electrical Work: • t r` -' r` • j r r ll table may be waived by the Inspector o Wires. • Compierton of theJucwrv�.s Total No.of Recessed Luminaires No.of Ceil.Susp.(Paddle)Fans F Transforo. mers IVVA • No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Above In- 'No.of kmergency Lighting Swimming Pool grad. ❑ grnd. ❑ Batter Units No.of Receptacle Outlets. No.of Oil Burners FIRE ALARMS No.of Zones • No.of Switches No.of and No.of Gas Burners• InitiatingDetection 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 Mumci al ❑ other No.of Dishwashers Space/Area Heating KW Local Connection No.of Dryers Heating Appliances KW Sec No.ofSDsvmsr Y g PP Devices or Equivalence rTh No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.II dxomassa e Bathtubs Telecommunications Wiring --- - y g No.of Motors Total H' No.of Devices or Equivalent • OTHER: I Attach additional detail if desired,or as required by the Inspector of Wires. 0 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 i1 BOND ❑ OTHER ❑ (Specify:) • I certify,under the pains and penalties of perjury,that the Information on this application is true and complete. FIRM NAME: Kc t)t(U)Loto Ptaiii43 My 4- f'et-9)0101;P d al . • LTC.NO.: :3j- Licensee:�2 C ThLn 114 W�.1i u Signaturepe:/e"---- LIC.NO.:9 1 S l ll(If applicable, "equip"in the license mother line) � t . Bus.Tel.No.:'S�l3S'3 G `. 16 Address: o l fr QIU�iiFtae `Jpi't Li A- 401 T'i-1r vhI 0 12� Alt.TeI.No.: *Per M.G.L.c.147,s.57-61,security wor 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 • _fequired by law. By my signature below,'hereby waive this requirement. I am the(check one)[]owner ❑(miner's mat. Owner/Agent PEI�1lIlTFEE: 7� Signature Telephone No. The Commonwealth of i►XassachuSetfs _: � Department oflndustrialAccidents �- _' r XCong• ress Street,Suite 100 • v4?` Boston, 02XX4 20X7 Workers' wwwmr�ssgov/dia. Compensation Insurance Affidavit:General Businesses.. A Izcant nfoxmatzon TO BEFIT,ED WITH TBE><ERMITTINGATJTI ORTTX, Please Brim Be ibl Business/Organization.Name;E.F.WINSLOW PLUMBING&HEATING CO.,INC Address:8 REARDON CIRCLE • City/State/Zip:SOUTH YARMOUTH,MA 02664 • Are you an employer?Check the a Phone#:508-394-7778 1.0 I am a employer with appropriate box: Business Type(required): . or art' employees(full and/ 5. []Retail p tune)•* • 2.D I am a sole proprietor or partnership and have no 6 Resfauranf/B ar/Eating Establishment 7. ['Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 3,❑ [No workers'comp,insurance required] 8 We are a corporation and its officers have exercised Non-profit • their right of exemption per a 152,§14 and 9• 0 Entertainment ( we have lD[Manufacturing no employees.[No workers'comp. 4.0 We are a non-profit organization taffed b insurancev rrequired]* 11.[�Health Care with no employees.[No workers'co y volunteers, ther Any applicant that checks box#1 must also fill out the n belowshowingtheir workers'compensation policy inibimation. **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. lam an employer That is providing workers'compensation insurancefor my employees. Below is the policy in ormation, ARROWMUTUALINSURANCECOMPANY Insurance Company Name; p y f Insurer's Address:23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL,MA 02457 • Policy#or Self-ins.Lic.#1821A Attach.a copy of the workers'compensation otic _Expiration Date:01/01/20� P y declaration page(showing the policy number and expiration date). ?allure to secure coverage as required under Section 25A of Ma c.152 can lead to the imposition of criminal penalties of a 'me up to$1,500.00 and/or one-year imprisomnent as )f up to o 00 dayagainstwell as civil penalties in the form of a STOP WORK ORDER and fine 'nvestigations of the DIA insurancetor. Pecov age verification..vised that a copy of this statement may be forwarded to the Office of do hereby certi , the and enalties oT y that the perjury information provided above is true and correct. . 1i nature: • 11 1-.. 'hone#;508-394-7778 Date; ) � � / rl Official use only. Do not write fin this area,to be co mplefed by city or town offtciaZ ' • City or Town: Issuing Authority(circle one): Permit/License# 1.Board ofHealth 2.BnildnrgDepartment 3.City/Town.-Clerk 4.Licensing Board 5.SeIectmen'• s Office 6.Other Contact Person: Phone#: • www.massgov/dia