HomeMy WebLinkAboutBlde-19-006198 or Commonwealth of Official Use Only
�� Massachusetts
Permit No. BLDE-19-006198
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:5/1/2019
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) 222 PLEASANT ST
Owner or Tenant BASS RIVER PROPERTY LLC Telephone No.
Owner's Address CIO FRANCIS V LLOYD III, 59 HILLTOP RD,CHESTNUT HILL, MA 02467
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 ❑ Undgrd 0 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Wiring of guest house.
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 ❑ 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: ANDREW M LEVESQUE
Licensee: Andrew M Levesque Signature LIC.NO.: 17318
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address:461 LOWER COUNTY RD, HARWICH PORT MA 026461831 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:$100.00
t)C ct (( ((1 -
Cer,L 714119 i6
Commonwealth o/Maddachadett4 OfficialC Use Only
•
"" �� ` 6 Permit No. l -
_�I_ 2)epaftMent O1.ire Serviced
Occupancy and Fee Checked
G-_I— 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 TYPE ALL INFORMATION) Date: `1 f Z[P l I o]
City or Town of: 'IM M J C� To the Inspector of Wires:
By this application the undersigns gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) r.-�-2- f)Lc ( -i c v -r Se U-ro yAX 0/1 CVT-1-i
Owner or Tenant IA/0 1 iP Telephone No.
Owner's Address
Is this permit in conjunction with a buildIing permit? Yes [J No ❑ (Check Appropriate Box)
Purpose of Building K Utility Authorization No.
Existing Service I (IL) Amps 1) (} / ()Volts Overhead❑ Undgrd ` No.of Meters
New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
Number of Feeders and Ampacity • (1 )
Location and Nature of Proposed Electrical Work: Uv ER., N (t r k-f 11 itovvyE 6j i,tec i f t vw
• .Completion of thefollowing table may be waived by the Inspector of Wires.
No
No.of Recessed Luminaires Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above L. In- 0 No.of Emergency Lighting
grad. grnd. Battery Units
e
No.of Receptacle Outlets No.of Oil Burners - FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detectionand - -
Initiating Devices
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste DisposersHeat Pump Number Tons KW_ No.of Self-Contained
_ Totals: I -� Detection/Alerting Devi
ces
No.of DishwashersSpace/Area HeatingKW Local❑ Municipal ❑ Other
Connection
No.of Dryers *SecuritySystems:*
�, Heating Appliances KW No.of Devices or Equivalent
No.of Water - .KW No.of No.of Data Wiring: '-
Heaters Signs Ballasts No.of Devices or Equivalentunications
No.Hydromassage Bathtubs No.of Motors - Total HP-- Tel Noeco.f Devices or Equivalent
OTHER:
• Attach additional detail if desired or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 1 Z��� _ (When required by municipal policy.)
Work to Start: t{ Inspections to be requested in accordance with MEC Rule 10,and upon completion. -
INSURANCE CO�RAGE: 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 N BOND 0 OTHER ❑ (Specify:) » •
-, • .
I certify,under the pains and penalties of perjury,that the information int this application is true and complete.
FIRM NAME:.N-WV I61+ fo RI ReA11t4 -r&DO 1.u� LIC.NO.: qrw 6
Licensee: 1/bi"r,S@�v Signature .007
.��(�� LIC.NO.:
(If applicabl freer "exempt"in the license number li ��� P� to Bus'.Tel.No.' . d 14
Address: tell � CAD "r( �� ��`a T 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. I PERMIT FEE:$ I L1
The Commonwealth of Massachusetts
�t epartment of Industrial Accidents
eft
Office of Investigations
_- = 600 Washington Street
Boston,]Vl9. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): Harwich Port Heating &Cooling LLC
Address: 461 Lower County Road
City/State/Zip: Harwich Port MA 02646 Phone#: 508-432-3959
Are you an employer?Check the appropriate box: Type of.project(required):
1.2 I am a employer with 75 4. ❑ I am a general contractor and I
employees(full and/or part-time).*
have hired the sub-contractors 6. [2 New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 12 Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition •
working for the in any capacity. employees and have workers'
[No workers' comp.insurance comp.insurance.
# 9. 2 Building addition
required.] 5. ❑ We are a corporation and its 10.2 Electrical repairs or additions
3.El officers have exercised their I am a homeowner doing all work 11.g Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t • c. 152, §1(4),and we have no
employees. [No workers' 13.[2 Other HVAC
comp.insurance required.]
*Any applicant that checks box#1 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
tContractors 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.
Insurance Company Name: AmGuard Insurance Company
Policy#or Self-ins.Lic.#: HAWC815956 ''- -( Expiration Date: 10/26/2018
,„ ,,
Job Site Address: �� l/� ?cSkt\1 l -� I City/State/Zip: V Y t-U V l t ►V `A
Attach a copy of the workers' compensation policy declaration page(showing the policy numbs nd expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead 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 and pen,3 f",s ofperjury that the information provided above is true and correct
Signature: Date: � �
( I
Phone#: 508-432-3959
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#:
Commonwealth of Official Use Only
'Ali
Massachusetts Permit No. BLDE-19-005856
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:4/18/2019
City or Town of: YARMOUTH To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to pertorm the electrical work described below.
Location(Street&Number) 222 PLEASANT ST
Owner or Tenant BASS RIVER PROP...'. , LLC Telephone No.
Owner's Address C/O �;: xh III, 59 HILLTOP RD, CHESTNUT HILL, MA 02467
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 sub panel in guest house.
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
Inttiatine 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/Alertine 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 perjury,that the information on this application is true and complete.
FIRM NAME: Andrew M Levesque
Licensee: Andrew M Levesque Signature LIC.NO.: 17318
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address:461 LOWER COUNTY RD, HARWICH PORT MA 026461831 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
LOCO"av oela (C r t, Udi U() �ql< k
j 3��c
Q 7/► Io1
iCommonuiea o1?addacIiudelid Official Use Only
—* _ L Permit No.
r =41i-i) fbepariment O ' ire epuice4
: Occupancy and Fee Checked
_t-f- .
',T.� 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) 527 527 CMR 12.00
•
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: t'f 10 / 11
City
or Town of: f�V�OU1� • To the Ins ector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) ��� FIX —r 9 6� co � YAM 0�
Owner or Tenant L-�0"t) Teleph ne No.
Owner's Address .
Is this permit in conjunction with a buildin permit? Yes ❑ Nojg. (Check Appropriate Box)
Purpose of Building Zie-C)4(0/k"--N Utility Authorization No.
Existing Service Amps 11.0 /2-Lf U 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: Jv ilk I N& O u g pArkle-L,
lob-�
I N fUL'cir t4in u r%
Completion of the following table may be waived by the Inspector of Wires.
No.No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans Tranof
•Transformers KVATota KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above In- No.of 1 mergency Lighting •
No.of Luminaires Swimming Pool grad ❑ grad. r-i Battery Units
9
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detectionand
1 Initiatinngg Devices •
Tot
No.of Ranges No.of Air Cond. 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 Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security stems:
*
rY No.of Devices or Equivalent
No.of Water . KW N .of No.of Data Wiring: - •
Heaters Signs Ballasts No.of Devices or Equivalent _
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of s Wiring:
or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of lec ical Work: I c1 o-D (When required by municipal policy.)
Work to Start: q Inspections to be requested in accordance with MEC Rule 10,and upon completion. • .
INSURANCE COVE GE: 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 Vir BOND 0 OTHER 0 (Specify:) .,� * R
I certify,under the pains and penaldes of pedury,that the information on this application is true and complete
FIRM NAME:.-1.16AVI I(+ 10 KT ReAT Nf 1 a)0 L[� C LIC.NO.: 3J ar 6
az
Licensee: t1c N�IA) ��� Signature A "``17 LIC.NO.: A 1 '
(Ifapplicabl rater "exempt"in the license number ii p� Bus:Tel.No.• , i _/7(
Address: IO l LW f �(ii! T Alt.Tel.No.: _I
*Per M.G.L.c. 147,s.57-61,security work r quires 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: $ 50
The Commonwealth of Massachusetts
Department of Industrial Accidents
'- feeOffice of Investigations
600 Washington Street
Boston,MA 02111
; . www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): Harwich Port Heating&Cooling LLC
Address: 461 Lower County Road
City/State/Zip: Harwich Port MA 02646 Phone.#: 508-432-3959
Are you an employer?Check the appropriate box: Type of project(required):
1.E3 I am a employer with 75 4. I am a general contractor and I 6 Q New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Eif Remodeling
ship and have no employees These sub-contractors have 8. El Demolition
working for me in any capacity. employees and have workers'
insurance.:
9. [y�Building addition
comp.
[No workers' comp.insurance
required.] 5. [] We are a corporation and its 10.2 Electrical repairs or additions
3.❑ I am a homeowner doingall work officers have exercised their 11. Plumbingrepairs
[� or additions
myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.[�Other HVAC
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 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.
tContractors 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.
Insurance Company Name: AmGuard Insurance Company
Policy#or Self-ins.Lic.#: HAWC815956 Expiration Date: 10/26/2018
Job Site Address: 2-'2-2" Y L 9d J 1 ,-SITCECT City/State/Zip:sou rna W+ MA
Attach a copy of the workers'compensation policy declaration page(showing the policy number and a iration date).
Failure to secure coverage as requrred under Section 25A of MGL c. 152 can lead 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 and pen,S es ofperjury that the information provided above is'true and correct
Signature: l / Date+ 1 O I
Phone#: 508-432-3959
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#: