E-19-6971 Commonwealth of Official Use Only
_ jtcillt Massachusetts Permit No. BLDE-19-006971
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:6/11/2019
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) 21 CAMELOT RD
Owner or Tenant MCKINLEY SUSAN J Telephone No.
Owner's Address 10436 S 66TH EAST AVE,TULSA, OK 74133-6703
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: Replacement boiler&water heater.
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 ❑ In- ElNo.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 1 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/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 1 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 ❑ (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
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�I- Thepartment o��`ire�erviceo
_ i_ Occupancy and Fee Checked
-_s, BOARD OF FIRE PREVENTION REGULATIONS [Rev.., ,4 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 1NFORMATIO11) Date: 6./5 / / 0
City or Town of: Yuf Thu i To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to erform the electrical work described below.
Location(Sheet&Number) 1\ t tr 10�- .d ye, i0v Ik 1'v1 t\ D .6
• Owner or Tenant Sv5crt K Ck 1Y1\-.Cyl Telephone No.gi 6,300g39
Owner's Address 1()y 6 S o.,) (' v4,54' P,ven u e 'Tv 15u U k 1 iii 1
Is this permit in conjunction with a building permit? Yes ❑ No: (Check Appropriate Box)
Purpose of Building .k),J e ts,A 6\ 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: f3 0\\ e( a r.(j 4)a 4,er I-et4 key ►✓l s IA/14-t/r0 n
Corniletion o the ollowin:table in, be waived b the Ins'ector o Wires.
No.of Recessed Luminaires No.of CeiL-Sus .(Paddle)Fans Tr
anansformers KVAPaddle Tf Total
p
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of.Luminaires Swimming Pool Above ❑ In- ❑ o.of"Emergency Lighting
• rnd. . nd. Batter Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
and
No.of Switches No.of Gas Burners No.Io Detection Detection
. 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 I
Totals:I I [._.•_._._ Detection/Alerting Devices
No.of Dishwashers Space/Area HeatingKW Local El Municipal El Other
pConnection
No.of Dryers Heating Appliances KWSecurity 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.Ilydromassage 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: 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
o— the Iicensee 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.
c.
U CHECK ONE: INSURANCE Ff BOND ❑ OTHER 0 (Specify:)
Q- c • I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRMNANA: gr CO(0. Lov) paten3t,Ufs 4 jq'T-20, ,,_I pC • LIC.NO.: 3 l -
Licensee:(ktC -4(/O fDAM) Signature tie/ LIC.NO.:9152`?
(If applicable,ent exen,: t,', in the license number line.) Bus.Tel.No.:5'08'3°r y'•77'lc�
Address: `� tI1'/'-d/DN GL i 6,f� . t 1,;Tl4 If/4-gg ,tttl-1t Ale 6yG4,` 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)0 owner 0 owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE:$
• . . ACC.OUNTSPAYABLE@EFWINSLQW.COM
The Commonwealth of Massachusetts
► ,c,Ml= l Department of Industrial Accidents
Taw iifl 11 • 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lezibly
Name(Business/Organization/Individual):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:
Type of project(required):
l.L:.J I am a employer with 888 employees(full and/or part-time).* 7. D 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. El Demolition
10 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOF repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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.
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:ARROW MUTUAL INSURANCE COMPANY
Policy#or Self-ins.Lic.#:1909A Expiration Date:01/01/2020
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 violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify and e par ss nd pen hies of perjury that the information provided above is true and correct.
o
Signature: Z^�
� �°' 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: 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#: