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Home My WebLink AboutBLDE-19-005954 Commonwealth of Official Use Only Massachusetts Permit No. BLDE-19-005954 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:4/22/2019 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) 132 GREAT WESTERN RD Owner or Tenant KNAPSACK WILLIAM J Telephone No. Owner's Address KNAPSACK MOLLY L,68 LAMPLIGHT DR, KENSINGTON,CT 06037-1806 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 200 Amps Volts Overhead 0 Undgrd ❑ No.of Meters New Service 200 Amps Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Replacement 200 amp service. 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. 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 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 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: 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 ''� _ Commonwealth o/Maasackudet iciiaall Use ,nl/ t 1 = _ft c/� Permit No. Q�k`i '— f S �1_ - 2"epartment of. ire Serviced 11= 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 TYP ALL INF TION) Date: II l7/)9 City or Town of: (�d( - To the Ins ecto of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. ( Location(Street&Numbee is a G r-re + ,'v' Re c,+e ,R . S. 'l a(f1'l D Owner or Tenant i I l O((Li Kri tySac k Telephone No.SoS'7(,O o971 q Owner's Address (pg. L6rnp 1i h-4 Dave , k.Pt15t'.i5 br GT 0 L'O37 l� Is this permit in conjunction with a ilding permit? Yes ❑ No V❑' (Check Appropriate Box) Purpose of Building cp v.) , t Y1 Utility Authorization No. Existing Service ZOO Amps /2O 2y0 Volts Overhead k1 Undgrd❑ No.of Meters New Service 200 Amps /26 /2 yO Volts Overhead g Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Q2(jo Amn EL 1 .-tC-a..P .Ui Ur tel 14Grm& • Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Paddle Fans No.ofTVA otal � Ceil.-Susp.(Paddle) Transformers KVA do No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.of Emergency Lighting No.of Luminaires Swimming Pool grnd. ❑ grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of No.of Switches No.of Gas Burners No.Initiatinnggon Dete and n Devices TotNo.of Ranges No.of Air Cond. T ns No.of Alerting Devices 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❑ Mon unici ion cpl ❑ Other (\j No.of Dryers Heating Appliances KW Securi Not of Devi es or Equivalent cNI No.of Water KW No.of No.of Data Wiring: CO Heaters Signs Ballasts No.of Devices or Equivalent No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: Y g No.of Devices or Equivalent a— OTHER: V 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. CHECK ONE: INSURANCE g BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: IBC Le)f LOa) PLttl'fli) vla 4` f-i- ifu6 . LIC.NO.: -3�?i L:., Licensee:12j(;(�4(L3 ill f l-�)IN Signature�' " G LIC.NO.:9/5'7?/4 (If applicable,enter`exem t:in the license number line.) Bus.Tel.No.��v8'3 i 11'?77 Address: 1 /Lt6f/l-0.00 6/feat SUltf i(iii-emoim-ii AM' Oy4G'c Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work 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,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:S A Signature Telephone No. `q ID ACCOUNTSPAYABLE@EFWINSLOW.COM .r A..rc. vw.tacviorrowcrsa WV iuuuuwa..awua.&.ru \ Department of Industrial Accidents Vim.l Office of Investigations f _ yi1 600 Washington Street _'i�i== Boston,MA 02111 ', www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers i.pplicant Information ` j Please Print Legibly 'Tame(Business/Organization/Individual): E��•W,,�St C,ni Q1Q: Jo'kvAc(il 1_ 1,-)tc,�1, ci.) I✓i( . \ddress: ccP ocevi C; 1Q. ',Ay/State/Zip: Sc,s 'c+r'Vs,A0 tkPc Phone#: '503- "q1-7'1? ire you an employer?Check the appropriate box: Type of project(required): =/ I am a employer with '70 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub--contractors ❑ I am a sole proprietor or partner- listed on the attached sheet.t Ill Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their .❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp.insurance required.] ,ny applicant that checks boz#1 must also fill out the section below showing their workers'compensation policy information. -iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site !formation. gg isurance Company Name: `,.s C 't J k O it •l it f oret n . n„ vl olicy#or Self-ins.Lic.#: ('3 a 1 Ac • ` Expiration Date: (—I _ aO2 )b Site Address: 3 G3n"&cYr1 --eck 4h }�'`'eI C�2�'l1(1O'l' Ail City/State/Zip: O{)L-I 6 7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Fup to$250.00 a da against the violator. Be advised t at a copy of this statement maybe forwarded to the Office of tvestigations the DIA for insura overage verif , on. do herebycc certify un e ains an penalties o p jury that the information provided above is true and correct. ignatuitei t Date: (a' 3 1 I ao hone#: cbY,:-"n`i - 7"7"7X 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.Electrical Inspector 5.Plumbing Inspector 6.Other V Contact Person: Phone#: