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Home My WebLink AboutBLDE-20-002084 ` Commonwealth of Official Use Only E Massachusetts Permit No. BLDE-20-002084 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:10/15/2019 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) 70 BLUE ROCK RD Owner or Tenant HAVERAN LAURA L Telephone No. Owner's Address 70 BLUE ROCK RD, 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 Amps Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity _ Location and Nature of Proposed Electrical Work: Replacement furnace. 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/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 A= Commonwealth,o/maddacha.detto Official Use Only �p t Permit e� '� ` i*_ cc�� cc77 C� l' 1 .Z)epartment oi,}ire Serviced 1( �4 * Qccupanc}y and Fee Checked °'- BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] "Qlr� (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 TYPEy ALL INFORMATION) Date: 10 old-N g City or Town of: I f fiyikri J1 To the Inspector of Wires: By this application the undersigned} Ives not'ce of his or her intention to perform the electrical work described below. Location(Street&Nuiiber) 7 O lUe gd ,k R I S, 14 r u 0) 6 6 I • Owner or Tenant L.at is 1'VA Vert( r Telephone No. 5Og 59 8 Z tit) I Owner's Address game . Is this permit in conjunction with a building permit? Yes I ( No.-� (Check Appropriate Box) Purpose of Building Awe.1�i h(� Utility Authorization No. Existing Service Amps J / Volts Overhead Undgrd n No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Anrpacity Location and Nature of Proposed Electrical Work: Ace h n,i h i a�1, � m Completion of the following table ma be waived b the Ins.ector o 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 Above In- o.o mergency Lighting -- — Swimming Pool grnd. ❑ grnd. 0 Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of hones — No.of Switches No.of Gas Burners No. • of Detection and Initiatin: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: W µ ,Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal n ❑C Other No.of Dryers • Heating Appliances KW Security ystems:* No.of Devices or Equivalent No.of Water aHeaters KW No.of No.of Data Wiring: Signs Ballasts No.of Devices or E,uivalent No.Ilydromassage Bathtubs No.of Motors Total HPTelecommunications Wiring: No.of Devices or Equivalent OTHER: c) Estimated additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) V\ 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 E BOND ❑ OTHER ❑ (Specify:) r- I certify,under the pains and penalties of perjury,that the information on this application is true and complete. T FIRM NAME: rc- c)fn5LOro Pu in3(,v(, <I. f- sig-Tibt s3 0,O, l ri.L. . LIC.NO.: :3�?S l C.— . -- '...0 Licensee:T tc4 0 j1 t t�,i j jtt) Signature ii_jf�'' LIC.NO.:9/871/4 1`n (If applicable,entgr"ex,,,em,pt,", in the license number line) v Bus.TeL No.:i c S'3°t y "7 I'�c T — �L Address: 1 g.�"(4(/�N r11f g- Sorb 4 ii14--einUtri-1 Ail' C�yb/ f 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)0 owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ • ACCOUNTSPAYABLE@EFWINSLOW.COM . 1 , The Commonwealth M oassachusetts f _,,M4= Department of Industrial Accidents Yll 1 Congress Street,Suite 100 .44-. f Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORTTY. Applicant Information Please Print Legibly 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): _-_ - - 1.1E Tame L.unployerwith employees-cfull and/or part-time).* 7. []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 doingall work myself. 9. El Demolition Y [No workers'comp,insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on m property. I will 10❑Building addition YP P tY• ensure that all contractors either have workers'compensation insurance or are sole 11.Q 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. These sub-contractors have employees and have workers'comp.insurance.# 13.0Roof repairs 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14.❑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 01/01/2020 Expiration Date: 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:underIVIGL 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 rho hereby certify and epaiyndp en ltias oferjury that the information provided above is true and correct.Signature: R 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#: