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Home My WebLink AboutBlde-19-005995 Commonwealth of Official Use Only 11- -••' Massachusetts Permit No. BLDE-19-005995 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 electncal work described below. Location(Street&Number) 23 HARPOON LN Owner or Tenant CARELLI CHRISTOPHER P TRS Telephone No. Owner's Address CARELLI JOHN R TRS,82 ANGELO ST,WORCESTER,MA 01604 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: Replace distribution panel. Completion of the following table may be waived by the Inspector f Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KV 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 VI 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 W Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alertinc 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 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 YJ/ SI((cq A / f"ie6 Commonwealth o/Maldachaleitl Of 1 Use Oinl � � Permit No. I. .(' I " 2epartment of ire Servicee v ' _ � Occupancy and Fee Checked So C. 1 == 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: 4 t ('I )3, ;.01) City or Town of: 7h0r(40"1, 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) ) 3 l i4 t Poor, I ti n't Owner or Tenant P L S(. C k f c II, Telephone No. 5vf 3)o- 19 7' w. •.... __..,..,._.__Owner's Address a 3 1-Iv r,„. a I'it)-L -. ;Is,' his permit in conjunction with a building permit? Yes — No 0 (Check Appropriate Box) ,3.; � L' P rpose of Building fr 51 af-t;.'4( Utility Authorization No. - E isting Service Ibis Amps 1 44 / '`1 o Volts Overhead El Undgrd ❑ No. of Meters 'I _- 7,-'1. w Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters "'t'4 mber of Feeders and Ampacity 1 W ` L _' L cation and Nature of Proposed Electrical Work: (Ellt,c-t. Phnhc,..c 1 LI<t-a,tk( f,to t " "- v •• - T Completion of the following table may be waived by the Inspector of Wires. No. 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 SwimmingPool Above ❑ In- ❑ No.of hmergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones oNo.of Switches No.of Gas Burners No. Initiating and on Devices No.of Ranges No.of Air Cond. Total g Tons No.of Alerting Devices 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 Connection ❑ Other 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 HI Telecommunications NofDevices or Wiring: No.of Devices Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: I)6(.1 (When required by municipal policy.) Work to Start: Pt(I 7(Xe 15 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 ® BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. 1 FIRM NAME: 1 luA� CI C(�r't 4 I Sca lei L�( LIC.NO.: a.21j d"A Licensee: Alit a (t✓ 7ko,4 Signature C%•- -- LIC.NO.: ,4)4 d'A (If applicable. enter "exempt'•in the license number line.) Bus.Tel.No.: le 17`31. - 2 T7 Address: 7 !:ch. k.c t 11,1 ti^n 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 1l t Department of Industrial Accidents s/'il�.r Office 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): l hCY\C. f ';cc_ c fv/1 ( �1, / f1 C. Address: 1'\Q_ City/State/Zip: 11._c 3: ._ Phone #: �9 j-"q g3 S Waif1 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with ' 4_ El I am a general contractor and 1 employees(full and/or part-time).* have hired the sub contractors 6. El New construction listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' insurance.f 9- ❑ Building addition [No workers' comp.insurance comp. required.] 5. [i We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1.1.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption MGL per 12.u Roof repairs insurance required.] t c. 152, §I(4),and we have no 13 [ Other employees. [No workers' _ .. m Q comp. insurance required.] Y C• f 'Any applicant that checks box#F1 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: St"' j ur —41 e JCh., Policy#or Self:ins.Lic.#: C 65 �-(..$) 2_0 Expiration Date: Job Site Address: 42� - City/State/Zip: JGU'-Yy crk 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 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 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# 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#: