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HomeMy WebLinkAboutBlde-20-000208 (2) _I 1 , _ Commonwealth.o/Maeaadu aej Official Use Only Pi 0 -ort Permit No. ‘10 (02.0� _�1 g .2epartmenl o f.ire Service6 - 114 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 TYPE ALL INFORMATION) Date: 07/04/19 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 electrical work described below. Location(Street&Number)22 Amelia Way Owner or Tenant Coelho,Terezinha Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate Box) Purpose of Building Residential Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters — --New Service -- --Amps— -1-- - Volts-- Overhead❑ Uudgrd ❑ Nitoof Meters- Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Convert existing branch circuit previously supplying an electric stove to a 120V branch circuit and receptacle for a new gas range. Completion of the following table may be waived by the Inspector of Wires. Nootal No.of Recessed Luminaires No.of Ceil:Sus .(Paddle)Fans Transformers of TVA P KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 15 temp strings Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets 1 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No. Initiating of Detectionand Devices 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 HeatingKW Local❑ Municipal ❑ Other P Connection No.of DryersHeating 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.H dromassa a Bathtubs No.of Motors Total HP TelecommunicationsNofDevices or qu in Y g No.of Devices Equivalent OTHER: E Attach additional detail if desired, or as required by the Inspector of Wires. 8 Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 07/03/19 Inspections to be requested in accordance with MEC Rule 10,and upon completion. E 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 N 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:) Cl. I certify,under the pains and penalties ofperjury,that the information on this application is true and complete oFIRM NAME: Rex Burger Electrical, Inc. '' MC.NO.: A21843 as Licensee: AJ Pulley Signature_ i i LIC.NO.: (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.: (508)250-2514 E Address: 2045 Main Street, Marstons Mills, MA 02648 Alt.Tel.No.: w *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. The Commonwealth of Massachusetts ► t !1. Department of Industrial Accidents __ _= 1 Congress Street,Suite 100 _ I _ ` Boston,MA 02114-2017 =c www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leltibly Name(Business/Organization/Individual): Rex Burger Electrical, Inc. Address: 2045 Main Street, Marstons Mills, MA 02648 City/State/Zip: Phone#: Are you an employer?Cheek the appropriate box: Type of project(required): 1.E I am a employer with 4 employees(fiill and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. t will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.Q Other 152,§1(4),and we have no 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. :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 employee& Below is the policy and job site information. Insurance Company Name: NGM Insurance Co Policy#or Self-ins.Lic.#: WCP8093V Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violationpunishable by a fine up to$1,500.00 ans1/pr 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.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: AJ Pulley,Vice-President Date: Phone#: 508-250-2514 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#: