HomeMy WebLinkAboutBlde-19-005245 .- Commonwealth of Official Use Only
Permit No. BLDE-19-005245
" Massachusetts
' _ ` 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•3/18/2019
City or Town of: YARMOUTH To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to pert e electrical work described below.
Location(Street&Number) 66 PINE GROVE RD (\Jig- (.1F"3a1)C1- 19—fV
Owner or Tenant Telephone No.
Owner's Address VE P 20
Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service 100 Amps Volts Overhead 0 Undgrd 0 No.of Meters
New Service 100 Amps Volts Overhead 0 Undgrd 0 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Upgrade service.
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil: No.of Total Susp.(Paddle)Fans 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 0 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 perjuiy,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: $75.00
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Commonwealth o/1addacLu6ett6 Official Use Only
p,= =gi Permit No. L �` i ^ J�4S
i�=_., cc�� c7
t=t. t— T e artment o a,_tire Serviced
7.',=-Ci-6"% Occupancy and Fee Checked
-,' 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),5 7 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 3 i}/I c/
City or Town of: Val.YY1 a To the Insp ctor of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical' ` work described below.
Location(Street&Number) (L(p �i n e (�-yl;Ve Rj S, yeti r i o l�'�Vl G a(G(c L L
Owner or Tenant DO 1 na LanC kkali S k j Telephone No. 7 7 y 57 3qq,5
Owner's Address ' 3 CYocke4+ RA m, 1“(J N{ A 0I 7
Is this permit in conjunc-t�ion with a building permit? Yes ElNo a (Check Appropriate Box)
Purpose of Building 1_JlJ)e A.to Utility Authorization No.
Existing Service j OLD Amps 1 Zd /"Zile. Volts Overhead RI Undgrd LI No.of Meters /
•
New Service /Ot? Amps /ZO/ ZyOVolts Overhead W( Undgrd❑ No.of Meters /
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: ,„ve1.0 / e,q Of. <SI trx t,.,e.6.— Phi e t m d'JF
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Sus . i Total
P (Paddle)Fans Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimmin Pool Above ❑ In- ❑ No.of Emergency Lighting
g grnd. grnd. Battery Units
v No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
J Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
g Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area HeatingKW Local❑ Municipal ❑ Other
P Connection
No.of Dryers Heating Appliances KW Se—c ty Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.H dromassa a Bathtubs No.of Motors Total HP TelecommunicationsNofDeieor Wiring:
u al
y g No.of Devices Equivalent
rfl
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: 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 [i BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NA IBC 10fNSLoto pl.tt.✓I'/3toi d.. ft "
rtt;6 . LIC.NO.: j iC�
Licensee:'',1-c{-,}(LQ gtv to Signature ../ LIC.NO.:9162?'4
(If applicable,enter"exempt:in the license number line.) Bus.Tel.No. 0g'3 cf�'�77/5
Address: `31 1L447--//DN 6rife 5vit ( i�i4MotEfi 41 API' Oy4�� L'S 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:$
LI
ACCOUNTSPAYABLE@EFWINSLOW.COM 4 1
SUA d M. t.t,n IILVIL I►4114434416 RAJ 1rALLJOLL4ILLLJ4n,
�- Department of Industrial Accidents
tr its / Office of Investigations
at "S 600 Washington Street
11 v= x Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
kpplicant Information ` g ` Please Print Legibly
L\Tame(Business/Organization/Individual): E•C•W+,nb I C,n; /�t0„.,to c,,na , O t h•n cie•, le-IC, ,
Address: 3` Oe( acv) C trck
City/State/Zip: Scu ' 'cro"c).. t-iPc Phone#: '501- 3cPi-1'1'1
kre 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
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
.❑ I am a sole proprietor or partner- listed on the attached sheet.I 7 ❑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
required.] officers have exercised their 10.0Electrical repairs or additions
❑ 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.]
1ny applicant that checks-box#1 must also fill out the section below showing their workers'compensation policy information. •
Homeowners 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.
isurance Company Name: vs C 01-t/c ,3_,' nst_r,2t el Ga. Car..• h-1.)
olicy#or Self-ins.Lic.#: 1 a 1 it Expiration Date: (--1 — au;x0
)b Gr Site Address: 3 vwAcw'1 vt.e eJh /�u'k r 21 CG\e. t(j4 IAA
iA City/State/Zip: 0,)'-1 b 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
'up to$250.00 a da against the violator. Be advised t at a copy of this statement may be forwarded to the Office of
tvestigations the DIA for. insura overage verif a on.
do hereby certify un e e ains an penalties o p jury that the information provided above is true and correct.
ignature; a Date: (a� 3 i I awl 3
hone#: SlY4: c i- 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
Contact Person: Phone#: