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Home My WebLink AboutBLDE-19-005244 Commonwealth of Official Use Only 4-: , Massachusetts Permit No. BLDE-19-005244 ..y z 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 LVFORMATION) Date:3/18/2019 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives nonce of his or her intention to pe the electrical work escribed below. Location(Street&Number) 66 PINE GROVE RD NyVaq C 14 4r.v icy Owner or Tenant VERNAL H DAVID Telephone No. Owner's Address VERNAL MARY F, 26 CHASMARS POND RD, DARIEN, CT 06820 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: Add on air conditioner. 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- ❑ 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 Initiating Devices No.of Ranges No.of Air Cond. 1 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 ❑ 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 ❑ 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 O_ -ffz ftY c _ //�7 nn'' fficial Use Only C,ommonu/ealth o/ adoacettS ? 19 � LE p _* Permit No. 'r = .i=_'t Thepariment Serviced =fit on ire Serviced V!1_ 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 TYPEALL INFO TION) Date:3/la jC City or Town of: a rm(� > - To the Ins ector of Wires: By this application the undersigns gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) (p(G' P ne 6V p VP , ,S, Y4(0not 4 11/114- t.2 Owner or Tenant ‘DO 6 V1 CC Leon c kL( Telephone No. 77`-f 573 ei D5 Owner's Address ,�3 [fo e cl , (4 rj k,(.I�} U 057 1 Is this permit in conjunction with a building permit? Yes ❑ No El- (Check Appropriate Box) CD Purpose of Building 1 A)-% ,t.ti t,q Utility Authorization No. 0 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: fie Co,C.G 4 (t oil der tij' L 0 C c/) Q Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Sus . PaeFans No.of Total V p (Paddle) Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires SwimmingPool 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 Initiating Devices V No.of Ranges No.of Air Cond. /) Total `� No.of Alerting Devices --� Tons r r.}� No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained t 'J Totals: Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Municipal ❑ Other p Connection C----. No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of No.of Devices or Equivalent Heaters KW Ballasts Data Wiring: Signs No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications N . fDeiceorq Wiring:l 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Es BOND 0 OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NA g ce1(OSLDu.) QLtt i'n-- (pi a" 4e L j,UX_ • LIC.NO.: . ,,/.61 — Licensee:' jam- tl-O 111, t�W jg Signature�i E LIC.NO.:9/8,??,4 (If applicable,enter"exempt':in the license number line.) Bus.Tel.No.•508'3 ll`77-75 Address: 1 /Lt617t(1oiU (iiff :j 5u1Ltf-I tjl4'�MOLLT 4, A� OY.6�� Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security worl 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)❑owner 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ CHI ACCOUNTSPAYABLE@EFWINSLOW.COM 0 SUAA Iii. VVIILIILVILII 4648L0L VJ lIi LWJLL4ILLLJI.LLJ Department of Industrial Accidents 41!MINN =.11wi . Office of Investigations * - 1= T 600 Washington Street fa: _' ! Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ,pnlicant Information CC ` , i Please Print Legibly lame(Business/Organization/Individual): L--•� W+A)1 evv Ojv �w1c( L. �-�tc� —, �e.) 1 el ddress: Qrato Eli ra' . ;ity/State/Zip: S 0,AwN kfcro,c), t`kPc Phone#: ' 0 - 394-1'1?'I re you an employer?Check the appropriate box: Type of project(required): I am a employer with 70 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet.# 7• El Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp. insurance required.] ,ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • -lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. (� isurance Company Name: 'D\.' s tli0A S'(c t el C a. \ t`stVici olicy#or Self-ins.Lic.#: ($a i ` Expiration Date: (—1 — DO2,0 )b Site Address: 3 Crv,rvetn vi.-e.--14"h . 1 C�2Z'11 J4 IA„ City/State/Zip: 0,7)14 b 7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Cup to$250.00 a da against the violator. Be advised t at a copy of this statement may be forwarded to the Office of tvestigations the DIA for insuranoverage verif a on. do hereby certify un a ee ains an�l penalties o p jury that the information provided above is true and correct. i attire:, / Date: (.. i ao a hone#: .cl) 35`4. 7?7D' 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#: