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Home My WebLink AboutBLDE-19-005601 Commonwealth of Official Use Only Permit No. BLDE-19-005601 Massachusetts 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:4/8/2019 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. u�y Location(Street&Number) 16 ICE HOUSE RD l7'Op( 9 - l l 56 Owner or Tenant WOLFSON BERNARD Telephone No. Owner's Address WOLFSON RITA, 35 CRESCENT ST APT 311,WALTHAM, MA 02453 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 oil 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- ❑ No.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners 1 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 ❑ 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 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 ,��i 7 11c 7 CGS /(( (( 9 M e Commonwealth.oil) aoeacelfi Official Usnl• y i*=**=° Aft Permit No. �' ( ,_9 —. �7 Tz-= ! g e artment o }ire-S7ervieeb -!`=6 Occupancy and Fee Checked ' _ BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) , 4 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code( C)'527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 14 3 19 City or Town of: \kr ill OU-f r1 To the Insp cto of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 1(40 I r Q 4 v`� 2�l S ya m( k 0 d-LoC.P L 4 Owner or Tenant s nai,1 w,`rus /1 f Telephone No.G i 7,,PC 7- '913d Owner's Address ,35 C re�-l�;i } .s A, , A p-I- 3 it ; w,t(- a C . � Is this permit in conjunction with a building permit? Yes ElNo [I'' (Check Appropriate Box) Purpose of Building Lit(,l(VI') Utility Authorization No. IN) Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Overhead Undgrd No.of Meters New Service Amps / Volts ❑ g ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 01 r go, ir ne r 4- 1ter ,ld t`kr.e c Inlet-ter lie Completion of the following table may be waived by the Inspector of Wires. 43 otal No.of Recessed Luminaires No.of Ceil:Sus . Paddle Fans No.ofTVA K P ( ) Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- O.of Emergency Lighting No.of Luminaires Swimming Pool grnd. .� grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners I FIRE ALARMS No.of Zones of No.of Switches No.of Gas Burners No.Initiating Devices Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Municipal ❑ Other P Connection No.of Dryers CI) Heating Appliances KW Security No. f Systems:* s or Equivalent (r No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent (1, No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications NfDeiceq Wiring:l Hydromassage 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 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 Ef 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 NA C( 0/O5LO1) pi-ttr' i't p(9 d- 4Z�- L I Itz. . LIC.NO.: '3j,,/c i 6- Licensee:( tC{-hW M,t VIN Signature LIC.NO.:9182Y% (If applicable,enter"ex�empt��' in the license number line.) Bus.Tel.No.:'S.v8'3 i 4•-7715 Address: 1 /Lt6i1I22/U (24K-ae 5Ulttf4 LfrkemU1t1t-4, AO 0'2-4 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 ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ ACCo I I G UNTSPAYABLE@EFWINSLOW.COM MIA 1 W. Lv,ssin cv/b,r t_tan,IV 1 Ill 6{J&D{LL/O•LJ[.cbu ' Department of Industrial Accidents ' vi .v/ Office of Investigations =, 'c 600 Washington Street _ Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers i.pplicant Information Please Print Legibly lame (Business/Organization/Individual): E'C.• In5 C,n; 4tVANto vir 2 0t�\1 c'e., lei( . kddress: eo evt C irc _ --lity/State/Zip: Sops k" 'cr4--,c3J1--1 NiPc Phone#: '5O - 39'1-11? kre you an employer?Check the appropriate box: Type of project(required): ki 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.I 7 ❑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 10.0 Electrical 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 12.0 Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] thy applicant that checks box-#I must also fill out the section below showing their workers'compensation policy information. Homeowners 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: ATY few k c.A ,.n,j`[_�CC.el C ,. \ el, i,i olicy#or Self-ins.Lic.#: ( (3'a I A - Expiration Date: (—] — aO2O Ab Site Address:,)3 CnrO.ACV1..p-e es-P1 A'i C\eZ`►y i4 lAl(( City/State/Zip: O,)Ll l,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 f up to$250.00 a da against the violator. Be advised tl�t a copy of this statement may be forwarded to the Office of tvestigations the DIA'for insura overage verif a on. do hereby certify un e .e ains an penalties o pe jury that the information provided above is true and correct. ignatu�e: r "" C A, \ Date: I D1 3 i i am hone#: szx 3cl - 7`7 7X Official use only. Do not write in this area,to be completed by city or town official. - • City or Town: 1 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#: