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Home My WebLink AboutBlde-22-003947 or Commonwealth of Official Use Only /AU 4- 4\ a Massachusetts Permit No. BLDE-22-003947 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:1/18/2022 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 descried below. Location(Street&Number) 4213 HEATHERWOOD C(2-4 C (A) (`1 Owner or Tenant Telephone No. Owner's Address BBLIINOWN541416 J,4213 HEATHERWOOD,YARMOUTH PORT, MA 02675 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: Upgrade devices, replace breakers, &add lighting. 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 Initiatine 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/Alertine 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 Ballasts Data Wiring: Heaters Siens 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: Jack W Griffin Licensee: Jack W Griffin Signature LIC.NO.: 418 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:26 JOANNA DR, S YARMOUTH MA 026641339 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: $50.00 1L +a , , C.ommonuua s/maddachulst t Official Use Only ; al e c7 Permit No. 2spartms ot ti�+s-Cervices {{— Occupancy and Fee Checked •y; Ik' BOARD OF FIRE PREVENTION REGULATIONS [Rev. (leave blank) t! APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code EC),527 CMR 12.00 cl (PLEASE PRINT IN INK OR TYPE ALL INRMATION) Date: / 77 O`a , . Qp City or Town of: Acelev To the In pee or of Wires: A) By this application the undersign giv notice of his or her,intention to perform the electrical work described below. Location(Street&Number) eod� k Ay,_{ (.aril 4' 1'A *IfiitilAPOPt 141!3 Owner or Tenant �`RA) (.�l I 1J Telephone No. L Owner's Address -PO 0t 1 ai® A' (.111, JCA'1 011M tfri+4 Is this permit in conjunction with a building permit? Yes 0 No (Check Appropriate Box) . Purpose of Building CoAioo c Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd 0 No.of Meters 11 Number of Feeders and Ampacity / hLocation and Nature of Proposed Electrical Work: 4 �p Q(/z�'�, 7`. a L 72l�✓t ki -ter B>�.v 1 ilk) °A'siv4i completion of the following table TransformersTotal be KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Poo, Above ❑ In- ❑ No.of Emergency Lighting g grad. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of No.of Switches No.of Gas Burners Vo. Initiatinnggon Dete and In Devices No.of Ranges No.of Mr Cond. Tonsl No.of Alerting Devices Disposers Heat Pump Number Tons KW No.of Self-Contained No.of Waste Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local 0 Mon is hal ❑ other No.of Dryers Heating Appliances KW No Securis:* of Dees or Equivalent No.of Water No.of No.of Data Wiring: Heaters ' Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Tel com No.of Devicesons or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of El trical Work: (When required by municipal policy.) Work to Start:f ‘7/ o9— Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE O RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liabili insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND 0 OTHER 0 (Specify:) I certify,under the ins nd penal ��perjury,that the Information on this application is true and complete. �l �( FIRM NAME: G r 1t LIC.NO.: of jE 7 l" Licensee:'T5 k 6y-t -rrv- Signature LIC.NO.: aS (If applicable xempt"in the licen um r line.) //L/ Bus.Tel.No.. -oZ al f Address: A ONA `pre 7412/r D i. (p(� / Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work quires 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 required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ The Commonwealth of Massachusetts r Department of Industrial Accidents _; 1 Congress Street, Suite 100 -�, �_ Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 6r'- lit) Address: J a A N� Ci /State/Zi tY Ptc plejlia0M- War Phone#: Q7F- 5/79 - (9 .5-02 Are y an employer?Check the appropriate box Type of project(required): 1. I am a employer with / employ •420.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.) 3.0f am a homeowner doingall work myself. 9. ❑Demolition y [No workers'comp.insurance requir ..]t 4.❑ my .party. I will I am a homeowner and will be hiring contractors to conduct all work on . 10ilding addition ensure that all contractors either have workers'compensation insurance or e sole 11.inrtlectrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on . e attached sheet. These sub-contractors have employees and have workers'comp.ins = e? 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of-• ption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.i .ce required.) *Any applicant that checks box#1 must also fill out the section . ow showing their workers'compensation policy information_ iHomeowners who submit this affidavit indicating they. ing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additi. al sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,thy- must provide their workers'comp.policy number. I am an employer that is providing wor -rs'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: y. /3 I k3'A-14 eie E S City/State/Zip: , 11A 1 a',r+ /41 I/ Attach a copy of the .orkers' compensation policy declaration page(showing the policytuber and expiration date). p ) Failure to secure . ,erage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year i to prisonment,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 tolator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veri .tion. I do hereby c.tify under ,:' and penalties of perjury that the information provided above is true and correct. Signature: ///y/ao2� Date: / Phone#: V 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#: