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HomeMy WebLinkAboutBlde-18-006803 V a Commonwealth of Official Use Only i ll% Massachusetts Permit No. BLDE-18-006803 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:5/31/2018 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) 17 AUNT EDITHS RD Owner or Tenant WILSCHUT ROY Telephone No. Owner's Address DRAPER DABNEY AMES,98 CANTERBURY WAY,BASKING RIDGE, NJ 07920 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appro. 'ate Box) Purpose of Building Utility Authorization No. o Existing Service Amps Volts Overhead 0 Undgrd 0 , o New Service Amps Volts Overhead 0 Undgrd 0 of•tC,I* ~ Number of Feeders and Ampacity 0 y Location and Nature of Proposed Electrical Work: Wiring of Hydro Air System(1st&2nd Floor) Completion of the following table may bGtr J." •t': Wires. No.of Recessed Luminaires _ No.of `T No.of Ceil. Susp.(Paddle)Fans Transformers No.of Luminaire Outlets No.of Hot Tubs Generators J� No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting 4)4 ' / 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 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: RICH M MELVIN Licensee: Rich M Melvin Signature LIC.NO.: 21829 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:8 REARDON CIR,S YARMOUTH MA 026641207 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 k., `14 3(( 3 (Kt i //// /I Official Use Only Commonwealth.o/Maddachudetid /S7 © 1 =*- —ft c� c7 Permit No. = 1 2epartr ent oi. 1re Serviced _ 5W 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 ),527 C 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMi ION) ate: _ 2 S— /8 City or Town of: (/4 0I.L7 l i e� o the Inspector of ires: By this application the undersigned gives notice of his or her intentio o perform the electrical work described bel w. Location(Street&Number) 11 r ( S 2 0. i n Owner or Tenant Q/ ir jjj1 LSGi-f-ilr. Telephone No. it '-� -�S-c.3 •0IF 0 Owner's Address Q e• CA 1l ._ ) thisIs {�gSiK//l a permit in conjunct' n with a buildingpermit? Yes n No (Check Appropriate Box) � Purpose of Building /Jt'L.//l4 Utility Authorization No. Existing Service Amps • / Volts Overhead❑ Undgrd L No.of Meters New Service Amps / Volts Overhead❑ Undgrd[ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: •p,e6 l/- s Sf Completion of the following table may be waived by the Inspector of Wires. r,,, . No.of Total \ No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans `Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.ofEmergency Lighting No.of Luminaires Swimming Pool grnd. ❑ grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Tot No.of Self-Contained , �' I Number I Tons_ I_K !.__..... Detection/Alerting Devices Other No.of Dishwashers Space/Area Heating KW Municipal Local❑ Connection AppliancesI Security Systems: No.of DryersHeating No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No of Devices or Equivalent UN Q\ 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 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. FIRM NAM K.r tot iiJ,5Lr�W PLCE.t'Y/IJt,UI.o 21' 4 t i '135bt4i LA i AZ. ' LIC.NO.: Licensee: 1 41,0 /14 f,L.UIr) Signature lit" LIC.NO.:r t 8', `1 (If applicable,ent "exem t"in the license number line.) Bus.Tel.No.: 15 Address: i j� k oN Hide 5oatf4 ttl motrrr-1t Apt OLb� Alt.Tel.No.: 'Per M.G.L.c.147,s.57-61,security work requires Department of Public Safety"S"License: Lie.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 a ent. '1 Owner/Agent PERMIT FEE:$ "1 Signature Telephone No. i "Ni 1 The Commonwealth of Massachusetts Tim f1 Department of IndustrialAceidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 �' "�. wwlvmassgov/dia ' Workers'Compensation Insurance Affidavit:Cfeneral Businesses.. TO BE FILED WITH THE PERMITTING AUTHORITY. Apulicant Information Please Print Legibly Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO.,INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664• Phone#:508-394-7778 Are you an employer?Check the appropriate box: 1.�]✓ I am a employer with- Business Type(required): employees(full and/ 5• 0 Retail or part-time).* 2.El I am a sole proprietor or partnership and have no 6 ❑RestaurantBar/Eating Establishment 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 3.❑ [No workers'comp.insurance required] 8. []Non-profit We are a corporation and its officers have exercised 9. 0 Entertainment • their right of exemption per c.152,§1(4),and we have 4.❑ no employees.[No workers'comp.insurance required]** 10.0 Manufacturing We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees.[No workers'comp,insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **Ifthe coiporete officers halt exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address:23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL,MA 02467 • Policy#or Self-ins.Lic.#1821 A Expiration I";Attach a copy of the workers'compensation policy declaration page(showing the policy nu berte: 0and0expiation 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 certi , the a' s and enalties o perjury that the information provided above is true and correct. Si nature: • Date: Phone#:508-394-7778 • Official use only. Do not write In this area,to be completed by city or town official City or Town' Issuing Authority(circle one); Permit/License# 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Licensing Board 5.SeIectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia