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HomeMy WebLinkAboutBLDE-21-000630 Commonwealth of Massachusetts Official Use -49(0. (r) l�y, . � Z--- t. Permit No. (0 C.C._ 7 „I � Department of Fire Services -_ - ' Occupancy and Fee Checked `— BOARD OF FIRE PREVENTION REGULATIONS [Rev. j (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: / -] /ZD City or Town of: yaw(Ali To the Inspector of Wires: By this application the undersigned gives notic4his pf or her intention to perform th- electrical work described below. Location(Street&Number) 321 .Iti Ul 0 ' i tV' Iv x/020/i. D Z. Owner or Tenant 6 C(A 1 Chi 1) 04 , In c" j-6r5 13eq.c1 Telephone No.5 0 k 86155 Owner's Address SCZYh( � Is this permit in conjunction with a building permit? Yes ❑ No (Check Appr,pion teo L. e Purpose of Building_COi11e1t/t1 al Utility Authorization No. i 'Iil a �^, Existing Service Amps ' / Volts Overhead❑ Undgrd❑ o e rg : ;' New Service Amps / Volts Overhead❑ Undgrd❑ o. eters o? I Number of Feeders and Ampacity �y �l l/�- ` 11 1 J �O Location and Nature of Proposed Electrical Work: I�r L Ili 5 IW r an � ''7`"'� I Com•letion o the ollowin:table mau:,ed '' l.L f o Wires.-•.: No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Trano. s . 1 40‘, dto 7 . ::;, 4V,41111e. 9747 No.of Luminaire Outlets No.of Hot Tubs Generators AboveIn- No.of Emergency ig 0 No.of Luminaires Swimming Pool grnd. r—i grnd. ❑ Battery Units I "-. No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zo es V . :/) No.of Switches No.of Gas Burners No.of Detection and I �` Initiating Devices Tota No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers IHeat Pump Number Tons KW No.of Self-Contained • P Totals: Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local Municipal ❑Other P ❑Connectio_n No.of Dryers Heating Appliances KW' SecuritySystems:* ry No.of Devices or Equivalent No.of Water KWNo.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications N . fDeiceor Wiring: No.of Devices 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: 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 ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this ap lication is true and complete. FIRM NAME: E.F.WINSLOW PLUMBING&HEATING CO., IV .LIC.NO.:3281C -- ' C) Licensee: RICHARD MELVIN Signature - LIC.NO.:21829A `p N (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.:508-3944778 .7"•" Address: 8 REARDON CIRCLE SOUTH YARMOUTH,MA 02664 E-MAIL:INSPECTIONS©EFWINSLOW.COM Alt.Tel.No.: it1 *Security System Contractor License required for this work;if applicable,enter the license number here: ZV% 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 I J owner's agent. Owner/Agent I PERMIT FEE: $ Signature Telephone No. The Commonwealth of Massachusetts 1—' Department oflndustrialAccidents =IV= E-411:2:1 �z 1, t Office of Investigations ,,_ ti= Lafayette City Center val ' 2Avenue 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. LI Retail 2.0 or part-time).* 6. 0 Restaurant/Bar/Eating Establishment I am a sole proprietor or partnership and have no 7El Office and/or Sales(incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. Li Non-profit 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.0 We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *My 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. ARROW MUTUAL INSURANCE COMPANY Insurance Company Name: Insurer's Address: City/State/Zip: * Policy#or Self-ins. Lic. #1909A 01/01/2021 Attach a copy of the workers'compensationExpiration Date: 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 ' e the ins and penalties of perjury that the information provided above is true and correct. Signature: L ,«.,.1.�.— 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.OBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.[]Licensing Board 5.0 Selectmen's Office 6.0Other Contact Person: Phone#: z____ — -