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HomeMy WebLinkAboutE-19-1602 l/ r Official Use Only or Commonwealth of Massachusetts Permit No. BLDE-19-001602 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:9/17/2018 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 electncat work described below. Location(Street&Number) 23 ANTLERS RD 62 r,q -- 15y- R i7d Owner or Tenant LARKIN SANDRA Telephone No. Owner's Address 23 ANTLERS RD,SOUTH YARMOUTH, MA 02664 Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check; 'propriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 Undgrd ❑ P. �. D New Service Amps Volts Overhead 0 Undgrd N. :I" . wM' Number of Feeders and Ampacity r� , Location and Nature of Proposed Electrical Work: Install generator. • Completion of the following table may tY, 9•, . -ctor of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Transformers No.of Luminaire Outlets No.of Hot Tubs Generators 1 KVA 7 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 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 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:) 1 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 YA (92414 =� `�" ( J2 ,4L / LJLIJ Nmor 2(71,9 lc rI PeiN c� (� - z� r--- __7__.:_ / Permit No, O Z 2eiaearttnent o 3 e Serviced yOccupancy and Fee Checked e BOARD OF FIRE PREVENTION REGULATIONS [Rev.�,,�.� (leave blank) APPLICATION FOR ;*ER MIT T PERFORM ELECTRICAL WEPRK All work to be performed in accordance with the Massachusetts Electrical Code( C),527 CMR 12.00 (PLEASE PRINT IN INK OR TYP,�,A7,,L 1VFO TON) Date: q ' 241 ' cCiiy or'Towrin of V� O� 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) _ ATI/M5 PPn ID Owner or Tenant `,4 424(i Telephone No. Owner's Address Ifs this permit la conjunction with a building ermai>!"? Yes No , (Cheek Appropriate I:r ox) Purpose of]milling �S.I Minty Authorization No. Existing Service 1 V(/ .Amps ��/ Wolts Overheats Undgrrd f_ No.of Meters New Service ' Amps / Volts Overhead 11 Urmdgrd No.of Meters Number of Feeders and ICI pacify • • Location and Nature of Proposed Electrical Work: tk Li(Z(I v 6e OP l►V U v1 Wa K .Completion of the following table may be waived by the Inspector of Wires. No. rams Total No.of l cessed L mihnaires No.of Ccenl.-Snsp.(paddle)Fans Transformers ICVA fornnaers �A No.of Lumbakre Outlets No.of Hot Tubs Generators KVA No.ofLaenaainaires ]Pool Above hi- ❑ No.oflnnergeney.Ligbtimg . grad, grand. Battery Units No.of Receptacle Outlets No.of Oil Burners . IFTREALARMS INo.of Zones No.of Switch es No.of Gas Burners 'No.ofDDetecfion and fitatingDevice No.of Ranges No.ofAir Cond. Totalo INo.of Alerting Devices Heat Pump .w umber Tons_ a iNo.of Self Coatabned No.of Waste Disposers Totals: - _.._. !t,etection/Alertlng Devices No.of Dishwashers Space/Area Healing KW 'Local Q Municipal o other Connection No.of Dryers Heating Appliances -eeurity stems:* •No.of spices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs ':Oasts No.of Devices or Equivalent . No. is ydromasssageBathtubs No.of Motors Total FIP Telecommunications Wittig: of Devices or Equivalent OTHER: • Attach additional detail Vdesireit or as required by the Inspector of Wires_ Eslhnated Value of ectdc Work: jOOV r-• (When required by municipal policy.) Work to Start: C)1 inspections to be requested in accordance with MEC Rule 10,and upon completion. • INSURANCE CO GE; Unless waived by the owner,no permit for the performance of electrical work may issue uirless - the licensee provides proof ofliability 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 X BOND ❑ OTHER [l (Specify:) • Icettify,render the pains and penalties ofperjrary,that the information on this application is true mid complete. • FIRM NAME:-14"-,AW ICH-PORT i-ilThl& h GOWN 6 f L-L.G 141C.NO.: i 7 1?)A- Licensee:ANDPEN 1, -. ,61.I4,-E Signature . . .x Sv sxol e MC.NO.: 35c'n(o (If applicable,enter `exempt"in the license number line.) Bats.Tel.No.: 5 08 L1-3P-.3q Address: fi i LOINfR. COUNT( 12OfiC ) v f1&4 poT ' F 2(04'(Q Alt Tel.No.: *Pea-M.G.L.c. 147,a.57.61,security work requires Department o Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: 1 am awarethat-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)El owner ❑owner's agent. • Owner/Agenture Telephone No. I.P.RI&IIT FEE:$ ' I The Commonwealth of Miss.i:chusetts r._. _- Department of Industrial Accidents "' _tr' l Office of Investigations `' d 600 Washington Sired `, -�- - / oston,MA. 02111 =- '. .s www.mass.gov/dia Workers' Compensation Insurance Affidavit: i ufiders/Conkractors/lectricia s/PIu tubers Applicant biformation Please Print Legibly Name(Business/Organivation/rndividual): 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.M I am a employer with 75 4. I am a general contractor and I 6 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. Remt ship and have no employees These sub-contractors have -_ T_8. 0 Demolition • wor ing for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp•insurance,* required.] 5. 0 We are a corporation and its 10.M Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.i 1 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12:111 Roof repairs insurance required.] i- c. 152, §1(4),and we have no employees. [No workers' 13_L d Other HVAC comp.insurance required.] - *Any applicant that checks box#1 must also fill out the section below showing their workers'oo sago p©licy. on:t. . t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contracts must submit a new affidavitindicating such tContractors that check this box must attached an additional sheetshowing the name of the sub-camtractors and state whether ornotthose entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policynnmber I am an employer that is providing workers'compensation insurance for my employees: Below is thepolicy 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-- (AVi1 0 City/State/Zip: + h/ llv l Attach a copy of the workers'compensation policy declaration page(showing the policynranber J(V1fl1OWf expiration date). Failure to set uwo coverage as required uutim Section 25A of MGL c. 152 can lead to the imposition of ariminalTpenalties 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 fuse of up to$250.00 a day against the violator. Be advised that a copy ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under therm and pens es of perjury that the information provided above is true and correct Signature: i Date: "(I /11I R . Phone#: 508-4.32-3959 `t 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 I Plumbing Inspector 6.Other Contact Person: - Phone#f: