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Home My WebLink AboutBlde-19-002405 Commonwealth of Official Use Only g-, Massachusetts Permit No. BLDE-19-002405 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/N INK OR TYPE ALL INFORMATION) Date:10/23/2018 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pertorm the electrical work described below. Location(Street&Number) 81 CROWELL RD Owner or Tenant LEITCH REALTY TRUST Telephone No. 5106 77oj= 8 Zq 9 Owner's Address J W&E L LEITCH TRS, 81 CROWELL RD,WEST YARMOUTH, MA 02673 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 ❑ c''. . ,4 eters New Service Amps Volts Overhead ❑ Undgrd 0 N• i� Number of Feeders and Ampacity LtdNtf Proposed Electrical Work: Install generator 4 P4LffiY Completion of the following table maya 'i b e Ir of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of 4otal Transformers A No.of Luminaire Outlets No.of Hot Tubs Generators 1 A 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 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 Siens 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: $75.00 1 to / -/ii f�� Peime... u� 4f a �.d-r1.0t7z4i6 6 Q / VI 7 I ii G •7/8/,9I / Commonwealth. / Official Use Only- \ Commonwealth.o/Maddachuoetts �/ ►�_ _At Permit No. l `l •_ 1—` Permit o/Jiro�eruiced t€ :_ Occupancy and Fee Checked_,___ j- BOARD OF FIRE PREVENTION REGULATIONS [Rey.1/07] leave blank). APPLICATION APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ),S27 CMR 12.00 (PLEASE PRINT IN.INK OR TYPE ALL INFO TI011) Date: 0 17 i b City or Town of: yal('v1/1,C To the Inspe tor f Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described'^ below. . L•ocation(Street&Number) l CYQ A)el( �S+ Yarr1rrivL I rc Ud -7 Owner or Tenant 6 I ea I/D r I-e I fill Telephone No. 7 75 Pg9 Owner's Address ,S q Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box) Purpose of Building t WQ,`I t Vl Utility Authorization No. Existing Service Amps• Volts Overhead E 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: G. .eA, f--- -- Completion of the following table may be waived by the Inspector o Wires. No,of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA KVA'tors No.of Luminaire Outlets No.of Hot Tubs Genera ------ Above .No.of Emergency Ligntmg No.of Luminaires Swimming Pool Hind. ❑ HindIn- , ❑ Battery Units ,t.r) No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiatin Devices No.of Ranges No.of Air Cond. Total No.of AIerting Devices OO — Heat Pump Number TonsTons lKW No.of Self-Contained a— No.of Waste Disposers Detection/Alexting Devices Totals: Municipal Appliances Other No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ HeatingKW Security Systems: No.of DryersNo of Devices or Equivalent �p No.of Water KWNo.of No.of Data Wiring: Heaters Signs Ballasts No gki/cos or Equivalent M Telecommunications Wiring: } No.Ilydxomassage Bathtubs No of Motors Total HP No.of Devices or Equivalent V" • OTHER: is 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 \t' 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 111 BOND ❑ OTHER ❑ (Specify:) • • I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: p r Ot ti)61.0 c1 pl Cf t4l i g.lxo <I" 4si4'-i010 0. l ia: , LIC.NO.: : 15'd ti Licensee. (-mil e 114 ti.11/g) Signature Lit, — LIC.NO.:9 1 S 2 !! (If applicable,ent "exempt"in the license number line.) i Bus.Tel.No.:`�GS `� j /7 Address: 1 i 0-1442 U GII Ct 5vlzi I tl i44ll4octr�L I i O'-k4 AIt.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 tequired by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's ent. Owner/Agent • PERMIT FEE:$ Signature Telephone No. C Of - /7O 1 Y vim. N t The Commonwealth ofMassacliusetts fir Department of IndustrialAccidents =iit�r 1 Congress Street,Suite 100 ' *` Boston,&1A021142017 www.massgov/dia • Workers'Compensation Insurance Affidavit:General Businesses.. TO BEFILED WITH THE PERMITTING AUTHORITY. A licantlnformation Please Print Le ibl Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO.,INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664. • Are you an employer? Phone#:508-394-7778 appropriate box: 1 I am a employer with 'Check the Business Type(required): . or part-time).* employees(full and/ 5. 0 Retail 2.0 I am a sole proprietor or partnership and have no 6 Q Restaurant/Bar/Eating Establishment 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 3.❑ [No workers'comp.insurance required] We are a corporation and its officers have exercised 8. ❑Non-profit [No workers• ' right of exemption per c.152,§1(4 9. jJ Entertainment no employees. )�and we have 10.0 Manufacturing comp.insurance required] 4.❑ We are a non-profit organization,staffed by volunteers, 11 CI Health Care with no employees.[No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infoimation. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. X am an employer that is providing workers'compensation insurance for my employees. Below is the Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY policy information. Insurer's Address:23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL,MA 02467 • Policy#or Self-ins.Lic.#1821A Expiration Date:01/01/20:: Attach a copy of the workers'compensation policy declaration page,[lshowing the policy number and expiration 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.. Ido hereby certi , the a' s and enalties o perjury that the information provided above is true and correct. Si nature ' °r Z-� . . Phone#:508-394-7778 Date: 1,1131 I I ri Official use only. Do not write in this area,to be completed by city or town official. City or Town: Issuing Authority(circle one): Permit/License# 1.Board of Health 2.Building Department 3.City/Town-Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: • www.mass.gov/dia