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HomeMy WebLinkAboutBLDE-21-003828 Commonwealth of Official Use Only ';II , Massachusetts Permit No. BLDE-21-003828 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:1/11/2021 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to ,..= oaf"the electrical work described below. Location(Street&Number) 183 SOUTH SHORE DR ,t, ?'k:_" : Owner or Tenant OCONNELL MARK A Telephone No. Owner's Address 43 DEER RUN, BELCHERTOWN, MA 01007 25,, Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appro ,j.e4 Purpose of Building Utility Authorization No. 44. Existing Service Amps Volts Overhead 0 Undgrd ❑ o r 4 m New Service Amps Volts Overhead 0 Undgrd 0 `i ' ,11de it, fag a Number of Feeders and Ampacity / ' 74, Location and Nature of Proposed Electrical Work: Renovations of kitchen&pipe bonding. V Completion of the following table may be waived by the In 0 ` ires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Tota Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators4SKVA No.of Luminaires Swimming Pool Above 0 In- ❑ No.of Emergency ghti grnd. grnd. Battery Units /„, No.of Receptacle Outlets No.of Oil Burners FIRE ALA S o.oZones C•,61‘ No.of Switches No.of Gas Burners No.of Detectio a i� 0 Initiating Devic '- J� �' No.of Ranges No.of Air Cond. TotaTons No.of Alerting De es�./, ti No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Q Obi Totals: Detection/Alertine Devi s <\'',C No.of Dishwashers Space/Area Heating KW Local ❑ Municipal 'x the Connection No.of Dryers Heating Appliances KW Security Systems:* '. ✓" No.of Devices or Equivalent No.of Water 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 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $100.00 Commonwealth of Massachusetts Official Use Only a•=" t Permit No. L=-J —363' 2b ;� Department of Fire Services Occupancy and Fee Checked \ _�4 BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(ME ),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFO TION Date: / b/2-1 City or Town of: a/I/A/ )/€ ) To the Insp for of Wires: By this application the undersignbd gives notice of his or her intention to perform the electrical work described below. Location(Street&Num/ber) /i )GY.t 2 S17/6-- � eve , Owner or Tenant M -0tCO,t 1_.&&J L Telephone No. 3 6/J/f; 2' Owner's Address YO in/I1-iLGH tG /-I T:5-J L 1, 4', iiiyl DAL-cb Is this permit in conjunction with a building permit? Yes El No ©Y- (Check Appropriate Box) Purpose of Building Pit i-lL J/Cv Utility Authorization No. Existing Service Amps / Volts Overhead El Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity / ,/J Location and Nature of Proposed Electrical Wpi•k: - L-/ ,"r 1 , _1-,e, %, j )df" /7"/t%. box;,© -7-C c_1',/2 c - 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 Above In- o.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 1No.of Deteon and Inn itiatinn Initiating Devices No.of Ranges No.of Air Cond. TotalTons 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❑Monnectionunicipal ❑Other C No.of DryersHeating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water No.of No.of Data Wiring Heaters KW Signs Ballasts No.of Devices or Equivalent ,...' Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent n 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 ® BOND ElOTHER ❑ (Specify:) . \ I certify,under the pains and penalties of perjury,that the information on this ap lication is true and complete. s FIRM NAME: E.F. WINSLOW PLUMBING&HEATING CO., I LIC.NO.:3281C Licensee: RICHARD MELVIN � Signature LIC.NO.:21829A fl (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.:508-394-7778 Address: 8 REARDON CIRCLE SOUTH YARMOUTH,MA 82664 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)Downer ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts t z Department of Industrial Accidents • ►: 1, Office of Investigations Lafayette City Center V..e7 Itk 2 Avenue 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 am a employer with 90 employees (full and/ 5. ❑ Retail or part-time).* 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#I. 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 ' 7 the ins and penalties of perjury that the information provided above is true and correct Signature: Y Date: 01/02/2020 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 2.1=I Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia —.ram 4�—