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Home My WebLink AboutBlde-19-005994 a O Commonwealth of Official Use Only Massachusetts Permit No. BLDE-19-005994 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:4/23/2019 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) 9 GINGERBREAD LN Owner or Tenant VILLANO GEORGE Telephone No. Owner's Address VILLANO MARY C, 5 LAKEVIEW DR, MILLSTONE TOWNSHIP,NJ 08535-1132 Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 100 Amps Volts Overhead 0 Undgrd 0 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: Wiring for mini-split&upgrade 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- ElNo.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 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.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: ANDREW G THOMAS Licensee: ANDREW G THOMAS Signature LIC.NO.: 22152 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:7 ECHO LN,CHATHAM MA 02633 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 I(f/,4 s/z°/t ' - 0/ (f3(fct Commonwea/tL o/2amacivaettd Official Use Only ` c� Permit No. j(� cco ll 1i 7..°"��lam - 2epartment o/Jire.ervicea �7(T/ c 7'�"' BOARD OF FIRE PREVENTION REGULATIONS Rev.O t/07 ccupancy and Fee Checked (leave blank) 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: Art,i a), aoi, City or Town of: Nr4((1'wi h 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) 9 G«,tit 31'c61 d 14 n t Owner or Tenant b c o( L V a 1 G n Q Telephone No. V ---Ovilner's Address 9 6•a bur P(twd lkn t. %y ?Is is permit in conjunction with a building permit? Yes El No Ell (Check Appropriate Box) 1 J.1.� V. , , : P; pose of Building f t s. 2 t n 1,6,1 Utility Authorization No. 1. 1/) -' ' E fisting Service 166 Amps 1 a o / a K 6 Volts Overhead E Undgrd E No.of Meters 1 - s Ems( 11 w Service �tsa Amps J au / z -io Volts Overhead I71 Undgrd n No.of Meters \ 2 IV tuber of Feeders and Ampacity Ji `T. L�ication and Nature of Proposed Electrical Work: o F br4 4 c at f tin C C fit e tl !";n, ,fit• Completion of the followim table may be waived by the Inspector of Wires. No. No.of Recessed Luminaires No.of Ceil.-Susp.p.(Paddle)Fans TranTotalsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above r—i 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.on Initiating on Dete and Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No. of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Municipal ❑ Other l 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 TelecommunicationsNofDeior Equivalent g No.of Devices F,quiva�ent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: .5I0o0 (When required by municipal policy.) Work to Start: Afl ui dl do)l 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 (S BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: 7 bL ,'.S l t(.l r i c ,� t, Vt(r LIC. NO.: r,1 t 5()—A Licensee: Al 2( t ti6: Signature C LIC.NO.: a 1 I y--A (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.: L 17"Q)f .2 79) Address: 7 'th6 )6to-c CMhil,,,n r•`1 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 Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts tri Department of Industrial Accidents ". =r,M tz Office of Investigations i �� 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �on E({C(fiG S t(V'cC f Address: b C 1'6 1 C City/State/Zip: C ti 4 l 1, h'. G t. C,7 7 Phone #: to l 7 - 5 3?” Are you an employer? Check the appropriate box: Type of project(required): 1.a I am a employer with 4• ❑ I am a general contractor and 1 employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.(�i I am a sole proprietor or listed on the attached sheet. 7. ❑Remodeling partner- shipand have no employees These sub-contractors have g El Demolition working for me in any capacity. employees and have workers' g comp. insurance.* ❑ Building addition [No workers' comp. insurance p required.] 5. ❑ We are a corporation and its 10.D Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions m self. [No workers' com right of exemption per MGL yp 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other_______ comp.insurance required.] *Any applicant that checks box tf l must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. L Insurance Company Name: S e l e_C- 1 v^ ects4- Policy#or Self:ins.Lie.#: r,qQ c Expiration Date: / / // Job Site Address: % CJ,?,�Gf�(� CdC �1 ea t City/State/Zip: /1/ly--eLJ714 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 MOL c. 152 can Iead 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License#f Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: