Blde-22-004248 _ 1 Official Use Only
Commonwealth of
1'E_ / Massachusetts Permit No. BLDE-22-004248
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:1/31/2022
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) 21 CANDLEWOOD LN
Owner or Tenant COLLINS DEBORAH A Telephone No.
Owner's Address 21 CANDLEWOOD LN,WEST YARMOUTH, MA 02673
Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead 0 Undgrd ❑ 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: Installation of solar PV system. (14 Panels 5.6 KW)
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. Batter,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
Initsatine Devices
No.of Ranges No.of Air Cond. Totalo No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: Detection/Alertine 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 KW No.of No.of Ballasts Data Wiring:
Heaters Sims No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or EauiviE(@gt _
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: SOLAR WOLF ENERGY
Licensee: Kyle Zuidema Signature LIC.NO.: 22593
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address: 771 Washington Street,Auburn MA 01501 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 my
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: $150.00
C��:. ,' .: Cr E I V ®
N 2 8 f:'tt , 2021 C ,nwsa[th of MaeeaeliuesNa Official Use Only
J "aliment
c�� n Permit No. = 4 S
R .,G D E PA RI-MEN T �sparfinsn�o f gip.Jsrv/ue
BUILDING U " '
By --- • BOARD OF RE PREVENTION REGULATIONS Occupancy and Fee Checked
`-_ (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:
-` City or Town of: q-Ac 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 do Number) 21 ('-AritQ(a jai 1.. 0 e
.
Owner or Tenant ael,�)(�rr Cc'1 I nS Telephone No.crfc -J(, C, 2
4
Owner's Address 9,i C`-Poci(.i?vaxxi ( f
( Is this permit in conjunction with a building permit? Yes J No 0 (Check Appropriate Box)
e Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead El Uudgrd 0 No.of Meters
- New Service Amps / Volts Overhead El Undgrd 0 No.of Meters
Number of Feeder and Ampadty
Location and Nature of Proposed Electrical Work: 1 RS.-�tni1G.k11 C (1LI\ ycO‘J Se ici pfheis io
,, -rtir&l (A 5.b t ) roc P iAt Sys re,
kn Completion of the followingtable m be waived by the Inspector of Wires.
�" No.O TotalI No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans Transformers KVA
Te. KVA
4 No.of Luminaire Outlets No.of Hot Tubs Generators
No.of Luminaires Swimsing Pool Above ❑ In- ❑ 1Vo.or Units
Lighting
grnd. ltrnd. Battery Unit:
-' 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
t I' No.of RangesNo.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers "Heati p Number Tons.__KW__ No
.Deot tion/f f-Contai
No.of Dishwashers Space/Area Heating KW Local 0 C onecdoa 0 Other
No.of Dryers Heating Appliances KW Security
of Devices:or Equivalent
No.of Water , No.or No.of Data Wiring.
Heater Signs Ballasts No.of Devices or iuiv�alent
No.Hydromassage Bathtubs No.of Motors Total HP Tel of Dro Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value
j
of Electrical Work: 4 Yt (When required by municipal policy.)
Work to Start:J -30-a l 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 cov is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE lff BOND 0 OTHER ❑ (Specify:)
I certify,under theepahn and penalties of ,that the information on this application is true and complete.
FIRM NAME: I la C 4- LIC.LIC.NO.: ),S93 P
Licensee: At,(_ ZV)GAin t Signature /'� LIC.NO.:
(If applicable,en _exempt"in the license number line.) Bus.Tel.No.S*S•SY-0146
Address: -17 -S a n at( PAt r (Y' inPi (')I S 61 Alt.TeL No.:
*Per M.G.L.c. 147,s.57-61, ecurity work requires Deportment 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/Agent PERMIT FEE:$
Signaturetune Telephone No.
f
The Commonwealth of Massachusetts
•
_1,r1= Department of Industrial Accidents
=e"cal_ 1 Congress Street, Suite 100
Boston, MA 02114-2017
wwx.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):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doingall work myself t 9. ❑Demolition
❑ y [No workers'comp.insurance required.]
•
4.❑I am a homeowner and will be hiring contractors to conduct all work on my p PAY•ro I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.El Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§I(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.
tContractors 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:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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 pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#:
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#: