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Home My WebLink AboutBLDE-21-004375 o. 4) Commonwealth of Official Use Only _ Massachusetts Permit No. BLDE-21-004375 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:2/2/2021 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) 5201 HEATH ERWOOD Owner or Tenant John Herr Telephone No. Owner's Address 5201 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: Add receptacles and lights. 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- CINo.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 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/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 Data Wiring: Heaters Siens 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: 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 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 E0-6.4 v///7 —. C,ommonwea6th o/Maadach.tkoeito Official Use Only t ):_*__ tt Permit No. �� —437 —AM_g cc�� vtel— t 2e�vartmznt of Sire Serviced 1L--- Occupancy and Fee Checked —= BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (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 INF,QRMATION) Date: f ZJ Z • �7'7'i To the In ec�tor of Wires: City or Town of: �.lZl�1?U P By this application the undersigns gives notice of his ori/her intention,tq perform the electriq work scribed below. Location(Street&Number) ... .:3.0 l J P.,4/N J0 ed--__ l r.fu1 U PO C Owner or Tenant N //3-e2 "rfTelephone Owner's Address ,S,q r Is this permit in conjunction with a building permit? Yes No. No I I (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead Undgrd( I No.of Meters New Service Amps / Volts Overhead I I Undgrd 17 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: A,®29jyj pl U,C y/ 1/Z ocia us OA f'�, A /,v,l ih IS-die— 7Y\Si h CO Fiti -r �,r P1 r3A/7 7 kZ c:41s' Completion of the following table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans 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 i No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other No.of Dryers Heating Appliances KW *Security Systems.. DNo.ofevices 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 o El ctrical Work: (When required by municipal policy.) Work to Start: I 'Z _Z4 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 age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penaltie,�, perjury,that the information on this application is true and complete (� J FIRM NAME: T _PGS,'1 44/1� LIC.NO.: 7 / Licensee: - �j i t.R v Signature LIC.NO.:Ec .c 9/ (If applicable, enter.�tempt"in the license number Ziff.) / Bus.Tel.No.: 97 -g7 9-4---001.--/ Address: 6 OCSANNl4 DK. So a pg-MeN i X46(PY Alt.Tel.No.: *Per M.G.L. c. 147,s.57-61,security work requiresrtment 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: $ Signature Telephone No. - 5. The Commonwealth of Massachusetts y �� ;� t Department of Industrial Accidents E till=_�.. Office of Investigations _,air _ 600 Washington Street e11 a Boston,MA 02111 ar ''-,.„•5' www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / ll Please Print Legibly Name (Business/Organization/Individual): �../ i k_ �i--,/2-/).)/-�' Address: cX JO A INA)14,1 0lc City/State/Zip:S ,4pl ez)14 Mil 6-)66y Phone#: 97r- v79 —2502 Are an employer Check the appropriate box: Type ofproject yp (required): 4. I am ageneral contractor and I 1. I am a empl with 6. ❑ w construction employee. 4 and/or part-time).* have hired the sub-contractors 2.❑ I am a sole .roprietor or partner- listed on the attached sheet. 7. MiRemodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. Ejnilding addition [No workers' comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10. Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other 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. Contractors 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.#: j Expiration Date: Job Site Address:S O/ A 74x (iooc& City/State/Zip: /yl7O/ j ,L,V Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 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 certify and, he p i ns and penalties of perjury that the information providedabove is true and correct. Signature: 41110 Date: J//o2 Phone#: �,•' ' Oip� ` 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#: