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Home My WebLink AboutBlde-19-004212 a! Commonwealth of Official Use Only (f(! Massachusetts Permit No. BLDE-19-004212 " 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:1/18/2019 City or Town of: YARMOUTH To the Inspector of Wires: c By this application the undersigned gives notice of his or her intention to pertorm the electrical work described below. �^�76-,acc/9 Location(Street&Number) 44 LEGEND DR =ije; !r1r,.I e! Owner or Tenant ARATHUZIK PAUL S elephone No. Owner's Address 44 LEGEND DR, SOUTH YARMOUTH, MA 02664 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 ❑ 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: 12 KW Kohler generator-trench&final(508-394-7778) 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) ❑ owner 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $75.00 - --1-1-ti\L“ i'CCINAD01,7" I Ad(? e __ 3l,a 'q//1(c V 7W4t- S f(q/(9 7e4 aseg 00W('(I? Le �// /I Official Use Only ar< I ammonwealth oo iaddachudett3 t/L� ►",=t 1t cc� cc77 Serviced Permit No.� /�/ — y" `7 —' 1=° 2epartnient o/ }ire Serviced .��1� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ey. . � �.�� [R 1/07] (leave blank) — • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ' All work to be performed in accordance with the Massachusetts Electrical Code(MEC),I527 CMR 12.00� (PLEASE PEINTIN INK ORTXPE ALL.INF0 T 01� I ' Date:()/ / f 4 . l City or Town of: \ _ (, • ; I To the Inspector of Wires: By this application the undersig d gives notice of is orç.Sc r intention t form the electrical work described below. Location(Street&Number) L r--C`P nc1 r'i • J� � r� Owner or Tenant f n() i i )sz- t 1 ti Telephone No. ��7 c'-) Owner's Address rn Is this permit in conjunction with a building permit? Yes L No _• (Check Appropriate Box) Purpose of Building U ( L)e ) Utility Authorization No. Existing Service Amps ' / Volts Overhead_• Undgrd E No.of Meters New Service Amps / Volts Overhead❑ Undgrd^ No.of Meters 0 Number of Feeders and Ampacity r- Location and Nature of Proposed Electrical Work: 'f • Completion of the following table maybe waived by the Inspector o Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Above In- 'No.of Emergency Lighting SwimmingPool grid ❑ grad ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones • No.of Switches No.of Detection and No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. TotalTons No.of Alerting Devices No.of Waste Disposers HeatTo PumpNumber Tons •••KW-••,,,... No.of Self-Contained als:I Detection/Alerting Devices Municipal Other No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ CP No.of Dryers HeatingAppliances Kr Security Devices or Equivalent No.of Water KWNo.of No.of Data Wiring: (n Heaters Signs Ballasts No.o£Deyices or Equivalent No.II dromassa e Bathtubs Telecommunications Wiring: 0 Y g No.of Motors Total HP No.of Devices or Equivalent • OTHER: •/ 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. (. 1 / 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. CHHECK ONE: INSURANCE 1 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: 69 r tt)(06Lot.0 PGCE4,4('Jt;ULo 4t" f[G`i4--VP��?i �.p. (tom , - LIC.NO.: `>•?�-.. Licensee: ,t(A�(Ln i'[ti-�tf� Signature %f G' ' LIC.NO.:r t 5 7 ' (If applicable,entrejj 18 'exe�mt"in the license number line) Bus.Tel.No.: �" f Lj 77 Address: / ill- •01"! ^ `,OO Glrezte 51�1bi'f� b1 t I�i0l fi'14i via 0"L '� AIt.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)0 owner ❑owner's eat. Owner/AgentJT ; ;;;: ;-i-iiiiIIi Signature Telephone No. 4 • The Commonwealth of Massachusetts G ,,. .� Department of lndustrialAccidents .T Congre ss Street,Suite 100 Boston,Mil 0211r s, • 4 2017 • Workers'Compensation compensation Insurance Affidavit:General Businesses.. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print)le 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? - —. Phone�;50$-394-7778 Check the appropriate box: 1. I am a employer with Business Type(required): . or part-time).* employees(full and/ 5. ®Retail • 2. I am a sole proprietor or patfnership and have no 6. ['Restaurant/Bar/Eating Establishment • employees working for me in any capacity. 7. 0 Office and/or Sales(incl.real estate,auto,etc.) 3.❑ [No workers'comp.insurance required] We are a corporation and its officers have exercised 9. Nonpofit • their right of exemption per e.152,§1(4),and we have 1 ❑manufacturing Entertainment no employees.[No workers'comp.insurance required]** 11.D Manufacturing 4.❑ We are a non-profit organization staffed by volunteers 11 Q Health Care with no employees.[No workers'comp.insurance req.] 12.❑Other *Any applicant that checks box 41 must also fill out the section below showing **If the corporate officers have exempted themselves,but the corporation has other e ployeesca workers compensation policy is required and such an organization should check box#1. X 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.Lie.#1821A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Expiration Date:01/01/20 ': Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties 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 of a against the violator. Be advisedthat a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certi the ads and enalties o 7711/ 1 perjury that the information provided above is true and correct. Si nature: '. fir -,rt Date: / _. i3/ / i Phone#:508-394-7778 • , 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 offfealth 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.SeIectmen's Office 6.Other . Contact Person: Phone#: • wvwumass.gov/dia 1