BLDE-21-002416 . -4p.
Commonwealth of official Use Only
Permit No. BLDE-21-002416
E Massachusetts
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:11/2/2020
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) 138 SWAN LAKE RD
Owner or Tenant CARROLL JANE CARROLL Telephone No.
Owner's Address 138 SWAN LAKE RD,WEST YARMOUTH, MA 02673 rl
Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appi�pQa)e ox ^�
Purpose of Building Utility Authorization No. ��``✓✓ J
Existing Service Amps Volts Overhead 0 Undgrd 0 '' I , 0 en
New Service Amps Volts Overhead 0 Undgrd 0 :. s
Number of Feeders and Ampacity O 117O
Location and Nature of Proposed Electrical Work: Installation of generator //
Completion of the following table may be waived b ,: . ,1*Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of i •
Transformers •
No.of Luminaire Outlets No.of Hot Tubs Generators 1 KVA 10
No.of Luminaires Swimming Pool Above 0 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 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:)
1 certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME:
Licensee: Matthew Gordon Signature LIC.NO.: 55830
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address:22 Station Avenue,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
r
Comnionmsaa o///lassach,ffs Official Use Only
/
-li�= • 2 cparfmant el.}ur Service! Permit No. 1 — �iL'I (
=,={-=`• ' Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/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.
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: / to /3 0 6
City or Town of: YARMOUTH To the Inspector of Wires:
By this application the Imdersigned gives notice of his or her intention to perf rm the electrical work described below.
Location (Street&Number) I 3 e �Wa v, Let�f r�
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ NoCheck Appropriate ppropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead E. Und
grd❑ No.of Meters
New Service Amps / Volts Overhead 0 Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: w;rj / q 5 e VIergtDr /0 ['t
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Cei1.-Snsp.(Paddle)Fans No.of Total
Transformers KVA
No. of Luminaire Outlets No.of Hot Tubs Generators /0 KVA
No.of Luminaires Swimming Pool Above ❑ In- 0 No.of 11mergency Lighting
=end. crud. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones
No.of Switches No.of Gas Burners No.of Detection and J
Initiating Devices
No.of Ranges No.of Air Cond. Total
Tons No.of Alerting Devices
Heat Pump Number Tons KW No.of Self-Contained
No.of Waste Disposers
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Loral❑ Municipal
Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of Water No.of No.of Devices or Equivalent
No.of
Heaters ' Data Wiring:
Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
OTHER:
No.of Devices or Equivalent
Attach additionl detail if desired;or as required by the Inspector of Wires.
Estimated Value of Electrical Work bbd
�
(When required by municipal policy.)
Work to Start /OO/2O 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,g‘ BOND ❑ OTHER ❑ (Specify:)
I ceriijy, under the pains...7/11
andenalties ofperjury,that the information on this application is true and complete.
FIRM NAME: ill ell/ c '6reit.
11
Licensee: �..�}��4LIC.NO.: 'f 5 1
= �� ,i/ .SOY Y1 Signature LIC.NO.:
(If applicable.enter "exempt"in the license number line.)
Address: Bus.Tel.No.: 77
J Per M.G.L.c. 147,S.57-61,security work requires Department of Public SafetyAlt Tel.No.:
— OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liabilityLin.No.
� insurance coverage norm— a(�
.. required by law. By my signature below,I hereby waive this requirement. I am the(check one 0 owner ❑owner's a ent_
Owner/Agent
1
Signature Telephone No. PERMIT FEE: $