BLDE-21-006894 en.
Commonwealth ofOfficial Use Only
MassachusettsPermit No. BLDE-21-006894
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev.1/07]
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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
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:5/27/2021
City or Town of: YARMOUTH To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to pertorm the electrical work described below.
Location(Street&Number) 30 SHORE SIDE DR
Owner or Tenant Dennis Howie Telephone No.
Owner's Address THE HOWIE CAPE COD RESIDENCE TRUST, 16 LITTLE MOUNTAIN ROAD, OLD TAPPAN, NJ 07675-7014
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: Install NC system.
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
Initiating Devices
No.of Ranges No.of Air Cond. 1 Total No.of Alerting Devices
Tons
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 ❑ Municipal ❑ 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: 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:$50.00
Commonwealth of Massachusetts Official Use Only
It *_
e
The Commonwealth of Massachusetts
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Department of Industrial Accidents
111-7:' — Office of Investigations
Lafayette City Center
•• i4"��—" 2 Avenue de Lafayette,Boston,MA 02111-1750
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~+°°° 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):
1.11 I am a employer with 90 ____ employees (full and/ 5. 0 Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.1 I I am a sole proprietor or partnership and have no 7• LI 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.I I We are a corporation and its officers have exercised 9. n Entertainment
their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]**
4.L] We are a non-profit organization,staffed by volunteers, 11.n Health Care
with no employees. [No workers' comp.insurance req.] 12.n 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.#1964A Expiration Date:01/01/2022
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 MOL 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 f' el•the and penalties of perjury that the information provided above is true and correct.
Signature: 1, �U• Date: 01/02/2021
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.[]Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.[]Licensing Board
5.[]Selectmen's Office 6.❑Other
Contact Person: Phone#:
www.lnass.gov/dia