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HomeMy WebLinkAboutBlde-20-001942 Commonwealth of Official Use Only Massachusetts Permit No. BLDE-20-001942 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:10/9/2019 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perto the electrical work docribed below. Location(Street&Number) 232 PLEASANT ST (,(47 ��t �� Owner or Tenant SEELEY ANNE BARUS(LIFE EST) Telephone No. Owner's Address 232 PLEASANT ST, SOUTH YARMOUTH, MA 02664 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: Re-bar grounding 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 0 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 Initiatine 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 ❑ 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 Siens 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: Lance A Macenerney Licensee: Lance A Macenerney Signature LIC.NO.: 11149 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address: 126A MID TECH DR,W YARMOUTH MA 026732560 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: $80.00 ACommonwea/IL o/Maaaachumeth Official Use Only ,� *- 41/ c7 Permit No. -tol q Z/ t �i 1 2)epartment o/Mire Services 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: 10 — i - I q City or Town of: \/Q(moo- 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) ,2 3 a, P I eS0.(\.\-- -'1.- Map Parcel# Owner or Tenant A1 a Levelnina.t Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / 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: � Yl-, C1 .. O u,nde,._k, 1.Ji' all Completion of the f ollowingjable may be waived by the Inspector of Wires. otal No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.roof VA p Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimmin Pool Above ❑ In- 0 No.of Emergency Lighting g 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 and Innitiatinnggon Devices. No.of Ranges No.of Air Cond. Total g Tons No.of Alerting Devices No.of Self-Contained No.of Waste Disposers Heat Pump Number Tons KW Detection/Alerting Devices Munic No.of Dishwashers Space/Area Heating KW Local❑ Connection l ❑ Other ` No.of Dryers Heating Appliances KW Security f 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 TelecommunicationsofDeieor Equivalent . 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.) 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 cover ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [[BOND 0 OTHER 0 (Specify:) I certify,under the ains and penalties ofperjury,that the information on this application is true and complete. ^ FIRM NAME: �tA, I I k( E II-� -C 6 1''q fY\ Y . LIC.NO.: `' Licensee: Lanee? or 6Eji tcrlt_ Signature LIC.NO.• (If applicable,enter"exempt"in the license numbet line) Bus. .No.: cel&)77 S—OC)�ja Address: )2i A M I D 1 -(,fir W Icy-MOW...kir\ Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Depuient 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: $ *IMPORTANT:A separate permit is required for the installation of smoke detectors.Fire Alarm inspections are performed by the FD having jurisdiction. Client#: 567950 2FULLEREL ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/17/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: The Hilb Group of N.E.dba PHONE FaX (NC,No,Ext):508 775-1620 (NC,No): 5087781218 Dowling&O'Neil Insurance Agy E-MAIL P.O. Box 1990 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Hyannis, MA 02601 INSURER A:Safety Insurance Company 39454 INSURED INSURER B:Safety Insurance Company 39454 Fuller Electric Company,Inc. NorGuard Insurance Company 31470 126A Mid Tech Drive INSURERC: I� Y INSURER D:Safety Indemnity Insurance Company 33618 West Yarmouth, MA 02673 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXPM/ LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MDD/YYYY) A X COMMERCIAL GENERAL LIABILITY BMA0024233 09/22/2019 09/22/2020 EACH q�OCCURRENCE $1,000,000 E CLAIMS-MADE X OCCUR PREMEaEooccc ur ence) $100,000 X PD Ded:250 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JECOT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ D AUTOMOBILE LIABILITY 6235164 09/22/2019 09/22/2020 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED AUTOS ONLY X AUTOSULED BODILY INJURY(Per accident) $ X AUTOS ONLY X NON-OWNED PROPERTY DAMAGE AUTOS ONLY (Per accident) X Drive Oth Car $ B X UMBRELLA LIAB X OCCUR CMU0005832 09/22/2019 09/22/2020 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$10000 $ C WORKERS COMPENSATION FUWC059001 09/22/2019 09/22/2020 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Operations performed by the named insured subject to policy conditions and exclusions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Health Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S242884/M242784 LS1