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Home My WebLink AboutBLDE-19-005953 Commonwealth of Official Use Only cl(41,11. Massachusetts Permit No. BLDE-19-005953 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 pertorm the electrical work described below. Location(Street&Number) 53 CAPT RYDER RD Owner or Tenant EVANS MARY A CO-TRS Telephone No. Owner's Address EVANS EVAN CO-TRS, 53 CAPT RYDER RD, SOUTH YARMOUTH, MA 02664 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: Replacement HVAC. 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 1 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/Alertinn 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.Hydro massage 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 0 OTHER 0 (Specify:) I 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 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 g. ( t (( Commonwealth.o/trlaeaacliuett6 Official Use Only' *- �- epartinent o�.7ires'fi Permit No. in ---; `� Serviced ' ;= BOARD OF FIRE PREVENTION REGULATIONS Occupancyand Fee Checked _ [Rev..1/0/071leave blank)) APPLICATION FOR PERMIT TO PERFORM EL All work to be performed in accordance with the MassachuMECTRICa o WORK setts Electrical Code(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: LI <li (q City or Town of: - �t 1 To the Inspector of Wires: By this application the undersignea gives notice of his or her intention to perform the electrical work described below. Location(Street&Nu ber) �j cL 9V4LLn -V 4t-r- Pl Owner or Tenant j) c, L. �ti l Y LAY YYG��,t h ,�� y Owner's Address Telephone No. 5 ,Y _,;Li3�5 Is this permit in conjunction with a building permit? �, Lk Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building i L. Existing Service Utility Authorization No. Amps _ / _ Amps / Volts Overhead New Service 0 Undgrd 0 No.of Meters --______Volts Overhead❑ Und rd Number of Feeders and An, aci� g El No.of Meters pa city Location and Nature of Proposed Electrical Work: j `t� + 1 � ��`L 6LJk 7 ' c ,vti _aL`f No.of Recessed Luminaires Com.letion o the ollowin.table in, be waived b the Ins.ector o Wires. �' No.of Ceil:Susp.(Paddle)Fans No.of No.of Luminaire Outlets Transformers Total v� No.of Hot Tubs KVA v~ No.of Luminaires Generators KVA Swimming Pool Above In_ `o.o mergency ig mg No.of Receptacle Outlets -rnd. :rnd. ❑ Batter Units No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners - - No.of Detection and No.of Ranges Initiatin_ Devices No.of Air Cond. Total No.of Waste DisposersTons No.of Alerting Devices Heat Pump Number .Tons I'No.of Self-Contained No.of Dishwashers Totals: Detection/Alertin Devices Space/Area Heating KW Local❑ Municipal rr' No.of Dryers Connection El Other No.of Water Heating Appliances KW Security terns:* le Heaters KW No.of No.of No.of Devices or E uivalent C.' Si_ns Ballasts Data Wiring: No.Hydromassage age BathtubsNo.of Devices or E uivalent No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E i uivalent Attach additional detail ifdesired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: Work to Start: (When required by municipal policy.) 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 mayissue the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. unless CHECK ONE: INSURANCE ,,,� q The I certify,under the pains andpenalties�ear OTHER 1 R information(Specify:) fP perjury, p y) FIRM NAM : '. nJ11U.SLocc) on this application is true and complete. Licensee: j -��,� 3 �` �• LIC.NO.: � (If applicable,ent "exem t"in the license number line.) Signature Address: Dti LIC.NO. 2/&2y, license 5Ur�4 !17 a• t� Bus.Tel.No.: G8 r 77�/� *Per M.G.L.c. 147,s.57-61,security work requires Department �� 6�� OWNOWNER'S M.G. INSURANCE WAIVER: I of Public Safety"S"License: Alt.�Tel..No. required ' law. Bymyam aware that the Licensee does not have the liability insurance coverage normally by la signature below,I hereby waive this requirement. I am the(check one ❑owner Signature q ❑owner's a�ent. Telephone No. PERMIT FEE:$ ACCOUNTSPAYABLE@EFWINSLOW.COM 454' / 6 r A fIndustrial Accidents, P. �\ Departmentof Investigations *� in pu Office of M 600 Washington Street "� Boston,MA 02111 bens '��= www.mass.g '� ww.rnit:Builders/Contractors/Electricians/Plumbers um ,� Please Print Le 'bl ovidia Yorkers' Compensation Insurance A Information �o��` licant Inform Q[�i:n.��vhc Le(Business/Organization/Individual): ress: CC �v J0/1 CAN Phone#: /State/Zip: °� Type of project(required): box: New construction Check the appropriateI am a general con-tractor and-IRemodeling Tout an employer? �� 4. I mp a employer with have hired the sub-contractors 6. ❑Demolition full and/or part-time).** listed on the attached sheet. employees( addition rono partner These sub-contractors have 9 Building I am a sole p employees insurance. workers' comp. 10.0 Electrical addition or additions ship and have no anycapacity.• 5 0 W e area corporation and its working for comp.in p11.0 plumbing repairs or additions required.] workers' insurance officers have exercised their exemption[No per MGL hoof repairs required.] right of 12.0 all work c.152,§1(4),and we have no ether I am a homeowner doing o workers' 2 0 myself.[No workers' comp. employees.[N required.] r comp•insurance req anon. ce required.]t policy inform such insurance compensation p y their workers'comppolicy information. must indicating fill out theare section below showing contractor and must u mit a new comp.p t doingall work and then hire ers'c mpena to n submit a new affidavit indicating • ractorantthat checks box# theyare showing the name of the sub thepolicyis and job site �eowners who submit this affidavit indicatingemployees. Below is ractors that check this box must attached an additional compensation insurance for my providing workers' ,t tan employer,that is p �--- `� an Name: Expiration Date: prance Company `$ a` Icy#or Self-ins.Lic.#: C ��` City/StatelZi number and expiration date). �ryvvku 1 vo-z,c V the policy penalties of a Site copy of: � page showing p compensation policy declaration p g ( imposition of criminal and a fine tack a copy the coveragewor a qump of a STOP as civil penalties in the form e forwarded WORK to the ORDERe of as required under Section 25A 1 GL c.l 52 can lead to the imp lure to secure q imprisonment,as well 500.a0 and/or against one-yearof this statement may e up to$1� a ainst the violator. Be advised tl�at a copy upto$250.00 a da g overage verif atj�on. • the DIA-for insur• provided above is true and correct. vestigations that the information p 1an t penalties o �;Jul' la 11 a�jl � � io hereby certify un e ♦ Date: ,�—•• 7 official.hone#: completed by city.or town off Official use only. Do not write in this area,to be ense# • off Permit/License City or Town: Issuing Authority(circle one): City/Town(Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1.Board of Health 2.Building Department 3. y 6.Other Phone#: Contact Person: