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HomeMy WebLinkAboutblde-19-000852 V.' ` a Nu Commonwealth of Official Use Only E` Permit No. BLDE-19-000852 _ Massachusetts 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:8/14/2018 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 electncal work described below. Location(Street&Number) 210 STATION AVE Owner or Tenant DENNIS YARMTH REGIONAL SCHOOL Telephone No. Owner's Address STATION AVENUE, 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 60 Amps Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Wiring of detached building on football field. 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 ❑ I r-nd. ❑ No.of Emergency Lighting grnd. gr 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: 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:$240.00 `t — g( (( lItilM rONY1..*. 0 1� Comm,.,rwea(tk of i/I//addack€i rll? vmciai use Lally -t / • s� Permit No, �—'l 31 —IF -. — .i 2),p.dment oigive Seruicea PI - ‘I'. Occupancy and Fee Checked TQ BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) PPU CATION FOR PERMIT TO PERFORM ELECTRICAL VIARK All work to be performed in accordance with the Massachusetts Electrical Code(MEC 527 CMR 12.00 • (PI:RASE PRINT IN INK OR TYPE ALL INFORMATION) Date: g I g City or Towini of: Y ttigillOVI-r-t+ 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) - 9-1 0 ST(k—r 1 0 N AVTi N U ii Owner or Tenants P.N N 1s t ift-g. O U-r- flIDNP(, scent, 015�(4 ]phonne No. Owner's Address - Ifs this permit in conjunction with a bunadlil�g' permit`? Yes I I No � (Cheek Appropriate I:�ox) Purpose of Building t OM YV1�fzC{kL, Utility Authorization No. Existing Service Amps / Volts Overhead[1 Undgrd No.of Meters New Service Amps / Volts Overhead❑ Undgrd No.of Meters Number of Feeders and Ampacity • Locatio and Nature of Proposed Electrical Work: IN i A(N& -Q 7A;�-( D t�[N&C�Z�� _sgeo Win .k' s12Vi w i-r-l{--E- - NGH ` D } InspectorofWires. of the following table may be waived by the YY�r s, No.of CVA otal No.of Recessed Luminaires naires No.of Ceit-Snap.(Paddle)Fans Transformers I If�A No.of Lunuinaire Outlets No.of Hot Tubs Generators TVA No.of Luminaires Swiaaaaxain )Pool Above ❑ In- ❑ No.of(Emergency Lighting • grad. 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 i Initiating Devices No.of Ranges No.of Air Cond. Tons 1No.of Alerting Devices Heat Pimp _cumber Tons ' '� !No.of Self-Contained No.of Waste Disposers Totals: {Detection/Alerting Devices No.of)ishwaslaers Space/Area HealingKW Local❑ Municipal ❑ Other P SCyonnection No.of Dryers Heating Appliances KW Se-No. of Devices or Equivalent No.of Water JKW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent . No.Hydromassage Bathtubs No.of Motors Total HPTeleco No.of Devices or Equivtions alent OTHER: • Attach additional detail if desired;or as required by the Inspector of Wires. Estimated Value of Electrical Work: litN K N J Y I f (When required by municipal policy.) Work to Start: c 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 winless 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 INI BOND ❑ OTHER ❑ (Specify:) • I certify,under the pains and penalties of perjury,that the information on this application is true and complete. - FIRM NAME:-1'F- IJiC -pDf2T L-k-T11 & I' co-6LrN&-.1 LLC, LIC.NO.: iq7tQ)A- Licensee:ARD PEIN 1,tV. .l e Signature LIC.NO.: 3 G, 11/(0•F. (If applicable,enter "exempt"in the license number line.) i ?�a� c6�6I, Re !s 2(a , , :us.Tel.No.: 5OgifSot;(1c Address: �(Ql L©1lw {<' COVN t"' fK(�cf� k1 I d' V\if T Alt.Tel.No.: *Per M.G.L.c. 147,a.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 agent Owner/Agent Signature Telephone No. I PERMIT FEE: $ 2!f 0 The Commonwealth ofMassac/ iser•s • Department ofllndustrialAccidents t (: iffice of Investigations k .;.--„a _,; 600 Washita:ron Street ,,. _._ oston,MA 02111 ., www.mass gov/dia Workers' Compensation Insura ice Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 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.Ea I am a employer with 75 4• ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. M New construction ' 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. M Remodeling shipand have no employees These sub-contractors have 8. ❑Demolition • working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.[a Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.M Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.[2 Other HVAC 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: AmGuard Insurance Company Policy#or Self-ins.Lic.#: HAWC815956 Expiration Date: 10/26/2018 Job Site Address: at 0 l Ve V 1 RI City/State/Zip: -S i L 1l4 41tr4'n.O1' M Attach a copy of the workers' compensation policy declaration page(showing the policy number and a iration 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 certify under the a and pen ' of perjury that the information provided above is true and correct Signature: Date: g I Phone#: 508-432-3959 {{{ 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#: