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HomeMy WebLinkAboutBlde-20-002395 (J C2O Commonwealth of Official Use Only fi-• Permit No. BLDE-20-002395 "mit\ 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:10/28/2019 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) 20 DRIVING TEE CIR Owner or Tenant CONWAY MARY P Telephone No. Owner's Address 82 PILGRIM RD, SPRINGFIELD, MA 01118-1414 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 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 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 ❑ 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 e \ Tele hone No. PERMIT FEE: $50.00 �Y.L—C? (l\'ly A 11!-_ NI &via(STA Bum c)AJ PANEL o Patiq crs 01- Otilf- - aY penis . ; - CommoruueaCth o//r/aMachcas Official UseOnly jr ft �7 Permit No. �1�-(�/VI 2 3qc ., z .bepartment of Jiro S'erviciM % _t Occupancy and Fee Checked 1 BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank) APPLICATI„N FOR PERMIT IT 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: 10/24/2019 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) 20 DRIVING TEE CIRCLE. SOUTH YARMCN 1TH Owner or Tenant CONWAY Telephone No.508.398.2845 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building RES Utility Authorization No. 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: WIRE ELECTRIC 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.ofTotalA P Transformers T{VA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.oiEmergency Lighting No.of Luminaires Swimming Pool grid. ❑ grnd. ❑ Battery Units , No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.In-Deten and Initiatingon Devices Tot No.of Ranges No.of Mr Cond. Tons No.of Alerting Devices Heat Pump Number Tons KW __.., No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices No.of Dishwashers g Space/Area Heatin KW Local❑ Municipal ❑ Connection Other p No.of Dryers Heating Appliances I Security Systems:* y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Eqquivalent No.H dromassa a Bathtubs No.of Motors Total HP TelNommue is io or Eqs uivalent y g 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 Le BOND ❑ OTHER 0 (Specify:) I certify,under the pains and penalties of perjury,that the information o s appli 'on is true and complete. FIRM NAME: e- F W/.N$1-v a accountspayable,_a: in w corn LIC.NO.:2),c?" �. 9/7 Licensee: R14i/cal & l. vi'iv Signature _ LIC.NO.://'' 7 ,g (If applicable enter"exempt"in the license number line) Bus.Tel.No.;J5ttpr a w 7778' Address: ' Ra.,A b e,v' C PoccL. S ,rf 1�ir.a diN/9 D,( tr q Alt.Tel.No.: 'Per M.G.L.c.147,s.57-61,security work requires Department of PublicSafety"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 PERMIT FEE: $ 50.00 Signature Telephone No. 514624 in junction w 514623 0 ` 0 ci ' . s-. 4 The Commbti veafth-of Ma sac/buse • r 3 :; /. Departm ent of lndustrurt,Ai ents' '. 1 Congress Street,Suite100 .. I r $ogtou,MA 02114-2617 • .�.1, www mass gov/dia Workers'"Compensation Insurance,Alidavit Builderss/Contraactors/Eiectricians/J1 unibers.: TOItt PH.Fh.WI1B.T -F.RRMti-ri1�IG AlrflitjRIM Anoiiean liife mabon: Pleaso Plant-Leuilii-. Nee e:(gusiti o• 4 oni dkv dual :E,F.witsIsLow PLUMBING-&HEATING Cq., INC: Address g:RE R N C1RGLE itylgtatealp UTH YtR'I°.0 -,MA112684 phone#.508,394-T778 Arc you an:empployer'Check tbe,appropriae box: Type of project(requited):: 1 ©.am•a,empldyer vi+iib 88 .entployecs(fails"and/or part tiine)' 7. ❑'New construction .f s amalesact aepl nT-p ia,and have no employeescwotking forme in 8. Reiilodehn ear eitY...ploweekers'comp iiiauiance.required] �' . 3 Di am aho-eownerdoang tl vrork-Myself jrio Work ers"comp..lttsuramierequiretta`t 9 0 Demolition it Eltstm a homeosiner^and will bens in ;contractors to soeduct ill' on my10 Q.Build iig rrtiditic ti .. � 8 property. I will imsu tba l ectlti�Ootr:ettliortrave workers'compensation Insurauccor areas le 11.( E1Ctri l- rs or'additibrns propnetota widen employees 12.CIPlumbing repairs•or.-additions 54:3 l am a;geobrdt.cor inctortn d.I'havr4grest.the sub-contiactorslisied on She attached sheet TkesasubobntragWt have employees acid have workers'comp,Ineurance.t 13.D Rocif repairs emption.per- L. 14.,DOd �'1%b. tuaotsaaa�anp�o, pwtadCeroisedthearrghtoP-eu . MGo. 15241(4)-andwe have.no,elirployc s.[;14o workers comp.insurance repaired:] "Any sp]tl .- t lib #1 must also'III1 rut th83 cttotlbelow showing-Meltwort-torte compensation ?olicy idfotmation: t Home+ovmcrs Wl w attbapipthraaflldo/'ttlrlthcatutg they are doing all work amid ihenitire.outsrdecot contractors most submit-a+ncW of davitind cstfttg such. ;font ties that,etteek'tlitilir iCmus*aktaoied.an additional shcershowinpibe name ofthe sub.coritmetoorao'd state whether of not those entitles have en11ploc4."1 tat 011tPloyees,t}tejr,ri litovideuhat workers'. It i!>nilmbt!" I am an eniplo,ytertliatisper_ ing rverkerst'conepensatlon Insurance for.inyepiployees, BelowBelowirthepolicpandieb.siite information. Insurance mpany i acne ARROW MUTUAL.IN.SURANCE;COMPANY Policy#or self in Lid.iC #.1.9/39A E tpiration Dater01/01/2.0 20 Job Site t ,-- .:Oily/State/Zip: -. : .. ' Attach a copy of the workers'compensation policy declaration page(sbowing•the policy number and expiration date). Failure;to secure coverage,,as require4`under 1VIGL o. 152,§25A is a criminal violation punishablerby a fine up to`S-1,5f 0: and/or one-year ampii'sonment,as Well as civil penalties in the form of a STOP WORK ORDER elide fine of eprto S250 00'a day against:the<violater A copy of this,statement may be foi ver'ded to the Office of Investigations.of the TIIA for msetranoe coverage venficatitli:. I de eby-cerlifv a'_ -ipe' flies of perjury thatthe information prov&�d above l true and correct it 5 ; _.a Date: Phbne 506-394-TITT8 j Ojfickil'use only. Do'nioi W,itte.frtilik area,to be completed by city orlown official City or Town: Permit/License# Issuing Authority(circle one): IBoard 2.81,1ld[ng Department 3.City/ToWn Clerk 4.Electrical Inspector -5.Plumbing Inspector 6.Other ContaetPerson::_ Phone*: