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Home My WebLink AboutBlde-19-006685 Commonwealth of Official Use Only Massachusetts Permit No. BLDE-19-006685 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked JRev.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:5/28/2019 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 electncal work described below. Location(Street&Number) 37 WEDGEMERE RD Owner or Tenant KORNER JOANNE L Telephone No. Owner's Address 37 WEDGEMERE RD,WEST YARMOUTH, MA 02673 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: Install furnace. 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. 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 ❑ 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 c47(d311te1 e. Commonwealth o/ModacluMettd O(ffiicialUse _Only lb —=eft Permit No. �—lQ"619`� -a,..IV---- ■_= 1= a artment o nire Serviced e —�(= ? P 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(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR 7 Yj'EALL INFORMATION) Date: 51I0 / /9 City or Town of: d ifIN To the Inspector of Wires: By this application the undersigned gives notice of his or her i tenlIt-.i9�nn to performer the electrical work described below. Location(Street&Number) mere Rr) lAks - 1 znav A (l c2 D -) 7 Owner or Tenant 3oanne, orner Telephone No. Owner's Address 5WML Is this permit in conjunction with a building permit? Yes ❑ No heck Appropriate Box) Purpose of Building `ll/1I Utility Authorization No. Existing Service Amps J / Volts Overhead❑ Undgrd❑ No.of Meters • New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Na ('(�' 50t w i tl —AilAka 1 AS1 tf/ j%04 • Completion of the following table in be waived b the Ins.ector 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 Above In- No.of Emergency Lighting No.of Luminaires Swimming Pool grnd. ❑ grnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.I Detectionand Inn itiatinngg Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Totals:I I 1 • _ .. .. I No.of Self-Contained p Heat PumpNumber Tons KW !'Detection/Alerting Devices .... Municipal Other No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ No.of Dryers Heating Appliances KW Security ystems:" y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.II dromassa a Bathtubs No.of Motors Total HP Telecommunications N . fDeiceorWiring:q l y g No.of Devices 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.) tt 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 O " undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. v, v CHECK ONE: INSURANCE Er BOND ❑ OTHER ❑ (Specify:) 2 I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NA gc 0fO. Lou) pLttm3tv(9 4- 4zi iff..10'L jt 40, 1iu'- . LIC.NO.: '3).61 L.- Licensee:'t -fi(LD ,fW INSignature LIC.NO.:9162?'4(If applicable,ent 'ex,em,pt',in the license number line.) Bus.Tel.No.: 5v8'39'i 77 78- Address: 1 A-M'I�UoN Gtf Lt; 51.)01-I (j/4-e/17vlz-H, Aft 0y664 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:$ Signature Telephone No. ACCOUNTSPAYABLE@EFWINSLOW.COM 4 • A i ' • �� .6166. C.iV 1Y6116V/61Y 6.6666/6 au 1IS66.Y.D 616.1666.1466V Department of Industrial Accidents I, aF_ _fl Office of Investigations =_i:11 600 Washington Street - ='i'}' Boston,MA 02111 „_ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E,C•`W,+ASkv0 QILIAJ0-1 0t0,k-: ce. teiC, Address: CcP ev1 Ci i Q., City/State/Zip: Soo kn Yor .,k t-Or Phone#: ' t) - 394-1'1? Are you an employer?Check the appropriate box: Type of project(required): "rElI am a employer with '7O 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.I 7 ❑Remodeling - ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in anycapacity. workers' comp.insurance. 9 p ty. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions I.❑ I am a homeowner doing all work right of exemption per MGL 11.0 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 belo-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. (� tsurance Company Name: 11//��fr a),..3 C` NA-V O A c il,1`uucu A CQ, \ os^etvely olicy#or Self-ins.Lie.#: 1$'1 A- - Expiration Date: (—1 ^ a o,:2z7 )b Site Address:a3 COnnnACri'1 V.'ee•-14"h ) Ci3 [A.1(i City/State/Zip: O,-)LI o 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 may be forwarded to the Office of tvestigations the DIA for insura overage verif a on. do hereby certint un e e ains u�e an penalties o p jury that the information provided above is true and correct. ignatt Date: (DI 3 I 1 aO i S hone#: .S Y,:3`l`i- 7 9•7 ' 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#: