Blde-21-000780 Commonwealth of Massachusetts ,,,,,;pffici1l like Only
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tom,,_ Department of Fire Services
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BOARD OF FIRE PREVENTION REGULATIQ�NS , eyy.:.3105.}-- eaveTiIaiik)
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APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
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(PLEASE PRINT IN INK OR ZYPE ALL/FORMATION) Date: ql/O,20
City or Town of: afMdl/ 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) fes c 51/ i4v viva 02
Owner or Tenant Novi(Ii(S ow t e Telephone Ng57 3 /5 =-
Owner's Address Sa rY e
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building 1)w.t1'j eti Utility Authorization No.
Existing Service Amps J / Volts Overhead❑ Undgrd n No.of Meters
New Service Amps / Volts Overhead❑ Undgrd❑ N .of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: B O1 LQ I i a 5/p]'Ln fit
Completion of the following table may be waived by the Inspector of Wires.
otal
No.of Recessed Luminaires No.of Ceil:Sus (Paddle)Fans No.ofTVA
P• Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimmin Above In- 1Vo.oI Emergency Lighting
g Pool grnd. 0 grnd. 0 Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.I Detectionand
Inn itiatinngg Devices
Total No.of AlertingDevices
R No.of Ranges No.of Air Cond. Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
P Detection/Alerting Devices
Totals
b. ••,,
I Yl..fyNo.of Dishwashers 5pace/Area Heating KW Local C nne Lion 0 Other
No.of D ers Heating Appliances KW SecuritySystems:*
rY No.of Devices or Equivalent
No.of Water KWNo.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring:
Y g No.of Devices or Equivalent
V 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.
b 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 ® BOND 0 OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this ap lication is true and complete.
(,_ FIRM NAME: E.F.WINSLOW PLUMBING&HEATING CO., IV .LIC.NO.:3281 C
C') tX4 Licensee: RICHARD MELVIN Signature • LIC.NO.:21829A
v (Ifapplicable,enter "exempt"in the license number line.) Bus.Tel.No.:
50e-394-7778
, r\t1 Address: 8 REARDON CIRCLE SOUTH YARMOUTH,MA 02664 E-MAIL:INSPECTIONS@EFWINSLOW.COM Alt.Tel.No.:
*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
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner n owner's agent.
Owner/Agent I PERMIT FEE: $
Signature Telephone No.
b1),
The Commonwealth of Massachusetts
Department oflndustrialAccidents
m t, Office of Investigations
our1,
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.I I am a employer with 90 employees (full and/ 5. 0 Retail
or part-time).* 6. 0 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. 0 Entertainment
their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]**
4.0 We are a non-profit organization, staffed by volunteers, 11.0Health 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 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. #1909A Expiration Date:01/01/2021
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 . e the ins and penalties of perjury that the information provided above is true and correct.
Signature: .«.�1� 01/02/2020
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(check one):
1.OBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.OLicensing Board
5.0 Selectmen's Office 6.DOther
Contact Person: Phone#: