HomeMy WebLinkAboutBlde-21-005700 Vo Commonwealth of Official Use Only
E Massachusetts Permit No. BLDE-21-005700
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:4/2/2021
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) 77 RAYMOND AVE
Owner or Tenant BOTTO CLAUDIA KOPF Telephone No.
Owner's Address BOTTO EDWARD;+; 51 MORAINE RD, MORRIS PLAINS, NJ 07950
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 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 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 ❑ 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: E F WINSLOW PLUMBING HEATING CO INC
Licensee: RICH M MELVIN Signature LIC.NO.: 21829
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address:8 REARDON CIRCLE, SOUTH YARMOUTH MA 02664 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 ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $50.00
42,, b s7 czi t
Commonwealth of Massachusetts Official Use Only
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'•_�i==c Permit No,
_ !M,_
�I_ Department of Fire Services
v (=_ Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Rev 9/05
j ((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 TYPE ALL INFORMATION) Date: 7,121 (' , I
City or Town of: "(afAAoUkk 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&Nu ber) 11 RiArrtS Ave So,�+fit Ymondv k!
Owner or Tenant VA 3a Telephone NoS0c6 ct 45 -i 6 1
Owner's Address 5l !'fit)faiyt , 0 I\AUfIi' S PC�t/1-S A 01 50
Is this permit in conjunction with a building permit? Yes El No (Check Appropriate Box)
Purpose of Building v '\k Ji(j Utility Authorization No.
Existing Service Amps •J/ Volts Overhead 0 Undgrd❑ No.of Meters
New Service Amps / Volts Overhead El Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Rolle/ 6ct5 t ict1 I Ilec4i / /A511446al
Completion of the following table may be waived by the inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.�addle T of T)Fans Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above In- No.of Emergency Lighting
No.of Luminaires Swimming Pool 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
Detectionn and
Inn Devices
No.of Ranges No.of Air Cond. Total
g 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 Heating KW Local Municipal
❑ ❑ Other
Connection
No.of Dryers Heating Appliances KW SecuritySystems:
No.of Devices or Equivalent
No.of Water KWNo.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: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
c INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
J\ 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 ® BOND ❑ OTHER D (Specify:)
.� I certify,under the pains and penalties of perjury,that the information on this ap lication is true and complete.
f---' FIRM NAME: E.F.WINSLOW PLUMBING & HEATING CO., I LIC.NO.:3281C
Licensee: RICHARD MELVIN Signature - LIC.NO.:21829A
(If applicable, enter "exempt"in the license number line.) Bus.Tel.No.:506-394-7778
S Address: 6 REARDON CIRCLE SOUTH YARMOUTH,MA 02664
Alt.Tel.No,:
(v *Security System Contractor License required for this work; if applicable,enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
P required by law. By my signature below,I hereby waive this requirement. I am the(check one)Downer 0 owner's agent,
Owner/Agent
Signature Telephone No. PERMIT FEE: $
' E.F. Winslow Inspection Department email : inspections@efwinslow.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
2Avenue de Lafayette,Boston,MA 02111-1750
�.. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 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: Business Type(required):
1.0 I am a employer with 90 employees (full and/ 5. ❑Retail
or part-titre)- 6. ❑Restaurant/Bar/Eating Establishment-
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp. insurance required]** 11.0 Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
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 information.
**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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. #1964A Expiration Date:01/01/2022
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under§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.
I do hereby cer 'f�-irtt�ef the ��ins andh penalties of perjury that the information provided above is true and correct.
Signature: � ` ``//''�1 f/ Date: 01/02/2021
7'�f/
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(check one):
1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board
50 Selectmen's Office 6.DOther
Contact Person: Phone#:
www.mass.gov/dia