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Home My WebLink AboutBlde-20-002627 �, Al Commonwealth of Official Use Only Permit No. BLDE-20-002627 �� 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:11/6/2019 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perto e electrical work d c ed below. Location(Street&Number) 92 BREEZY POINT RD 1 . Y�vtp7S T1-- Owner or Tenant Telephone No. Owner's Address L1� y� Is this permit in conjunction with a building permit? Yes 0 No 0 ( 1Ri�x) v ,s tJ PurposeUtilityAuthorizationNi 7 ` +3 1' P Buildingram i Existing Service Amps Volts Overhead 0 Undgrd 0 tr" New Service 100 Amps Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install third service for septic equipment. 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. 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 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: Michael F Simonis Licensee: Michael F Simonis Signature LIC.NO.: 16862 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:PO BOX 1488, EAST DENNIS MA 026411488 . 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: $75.00 c Ult N u (i hct feg- r . • $a Comaiosinaii 4ma,..4.,.th ,°mad Use Only • • I �� _.brvlcee Permit No. C5J'' J 2'7 -\ '" Occupancy and Fee Checked qj BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank) is 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: l l t. .5—I t 9 City or Town of: YN--1N.d u' To the Inspector of Wires: Jfond By this application the undersigned gives notice of his or her intuition to pan,u the electrical work described below. Location(Street&Number) `-t02 cZ - -Z .{ -Po t v.i-f Q Owner or Tenant 'D rr 1J' v S s kj t G 1A-c-[ Telephone No. .. Owner's Address S('s -4'e-- v Is this permit in conjunction with a baildleg permit? Yes 0 No ® (Check Appropriate Box) 4) Purpose of Biding a f- L t._-t b t�Q-1(t N;c7 Utility Authorization No. a 3 C.,? a-`k cA Existing Service a-m o Amps 12 -o / -(o Volts Overhead[' l Uudgrd❑ No.of Meters a- a clew Service l m D Amps C2- /a`f o Volts Overhead[�- Undgr d❑ No.of Meters 1 Number of Feeders and Ampadty.it 2 ,e-4-t F t.4) 1n Location and Nature of Proposed Electrical Work: ..J.1 s't,f-c-L ,seb D t n e 6.i. _ •-po is•L_t c. PA-,..) L. •0 -F't-ot'\ tv-t5 'r'1N(v 3 9,4.Jcr M.k.QYc.T S0LKer (--B-e.tNS vSe-b G0d'f'-enrW4 V9 Completion of ihefollowr+�tabk be waived by the htsisector of Wires. rt i of Total No.of Recessed Luminaires No.of Ceil.-Sew.(Paddle)Fans Tra rmers ICVA No.of Laminalee Outlets No.of Het Tubs Generators KVA No.of Luminaires SwimmingAbove ❑ In- ❑ trot e Emergency uey Lighting Pool grad. end. Battery Units No.of Receptacle Outlets No.of OB Burners FIRE ALARMS No.of Zones 't Detection and z. No.of Switches No.of Gas Burners No.o Devices Total Ill No.of Ranges No.of Air Cond. Toro No.of Alerting Devices No.of Waste �Pump Number Tens.. 1 KW.___.. 1%.of Self-Contained Totals: _ Detecdoa/AieDev'lees eicipal No.of Dishwashers Space/Area Heating KW Local❑ MCoaneetlon 0 Odes' No.of Dryers Heating Appliances KW Security .* No.ofSl or Univalent No.of Water No.of No.of Data Wiring: KW Signs Ballasts No.of Devices or , t No.Hydro w mage Bathtubs No.of Motors Total HP Tel No.of Devi ores. , OTHER: r...J rn-e ,cprtc (4)1 c.E-t P..w t>5 +Co-t.ett`o I i7A-v•w_.I Attach additional detail tf desir+ed or as required by the hapector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: t l\ to I t `1 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 (a- BOND ❑ OTHER 0 (Specify:) l r— c-U4-e-`Pc Icy,ander the pains and penalties ofperjury,that the Wortnation on this application is roe and complete. FIRM NAME: 5 t w.o A):% t,e LT2,c =.N G LIC.NO.: tot t to g 6 Licensee: 1--(«lea--..l S t wk.s r S Signature js/ -�� 7 LIC.NO.: t 3 oa 3 g (If applicable,enter"exempt"to the license manlier line.) r ( Bus.TeL No.:CZR-g 8 r- $'b g7 Address:P-6 • 0o K. 1 K t C 'E, n� S, ji 4 a. O Co 4-E 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)❑owner ❑owner's agent Owner/AgentSignature Telephone No. I PERMIT FEE:5 The Commonwealth of Massachusetts %h Department of Industrial Accidents I Congress Street,Suite 100 � �= t 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 Legibly Name(Business/Organization/Individual): I n.•t --v1. ,J4 Address: `P. .g'g City/State/Zip: rse t^"- as Co 4 ( Phone#: So —g g g--' g > Are you an employer?Cheek the appropriate box: Type of project(required): .11 I-i n a employer with .2 employees(full and/or part-time).* 7. Q New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself. ] 9. ❑Demolition [No workers'comp.insurance required t 4.0 I •are a homeowner and will be hiring contractors to conduct all work on my property.ro I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 5.12 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurances 13.El Roof repairs 6.0 We are a corporation and itsofficers have exercised their right of exemption per MGL c. 14.0 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. tContracmrs 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: DTP,-cl..e I-e r - . Policy#or Self-ins.Lic.#: (te,b 6$ ( O Expiration Date: 7 1o�s----J t Job Site Address: to� 3r'ee2 y } t N ? P o City/State/Zip:'VA-r-wA.o v t'l M 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 under the pai>' and penalties of perjury that the information provided above is true and correct. Signature: Date: 1 / 7 Phone#: g7 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#: