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Home My WebLink AboutBLDE-20-005561 o. . Commonwealth of Official Use Only =i.:,, ,10, T ' Massachusetts Permit No. BLDE-20-005561 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked JRev.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:4/27/2020 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) 99 BUCK ISLAND RD Owner or Tenant TOWN OF YARMOUTH Telephone No. Owner's Address WATER DEPT, 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4463 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check A! i 's)i e Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 Undgrd ❑ o : s0 New Service Amps Volts Overhead 0 Undgrd 0 n/, Number of Feeders and Ampacity A �''' ,31)Location and Nature of Proposed Electrical Work: Replacement roof top equipment. 0 Completion of the following table may be waive t i gr of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of 7/i A Transformers 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 1 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 ❑ 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: CHARLES K SWANSON Licensee: Charles K Swanson Signature LIC.NO.: 12895 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:718 CEDAR ST,W BARNSTABLE MA 026681300 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: $0.00 • Official Use On CommoawsaEth o/maeeac�aaslte ly c2,O— `c( ( l ( 2sparfmsnE o�.�fis ServicedPermit No. �v �' 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 INFORMATION) Date: (- z`l- 20 City or Town of: \h,t,--0^0(d 7 k 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) `--Y1 3-,ck d-S l G 1 J le(f Owner or Tenant \(c.. �i 1^ wG 1` Lfc i t Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 0 No [ ' (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd 0 No.of Meters New Service Amps / Volts Overhead 0 Undgrd❑ No.of Meters Number of Feeders and Ampadty Location and Nature of Proposed Electrical Work: L)t;'C.., ft l Ccscet4 Ai tG f'--'t of l(c�i i Al .. 6, (--el uor t h ! Completion of thefoUowing table may be waived by the lnsvecfor of Wires. No.of Total No.of Recessed Luminaires No.of CeIL-Snap.(Paddle)Fans Transformers KVA Q No.of Luminaire Outlets No.of Hot Tubs Generators KVA a AboveIn- No.of Emergency Lighting -t No.of Luminaires Swimming Pool fond. ❑ fid. ❑ Battery units J No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones It ! No.of Switches No.of Gas Burners No.of Deteon and � Initiating Devices 1 LI No.of Ranges No.of Air Cond. I Total on 1 S— No.of Alerting Devices Heat Pump Number Tons KW rTo.of Self-Contained No.of Waste DisposersTotals: �_ Detection/AlertinaDevlces No.of Dishwashers Space/Area Heating KW Local 0 MunieciPaln ❑ Other No.of Dryers Heating'�ppliancea ' SecNo.ofDevices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equiidvagglent No.Hydromassage Bathtubs No.of Motors Total HP TelNo.of Devices or Equivalent OTHER: c Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 500 (When required by municipal policy.) Work to Start(1-1`t- 20 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 0 OTHER 0 (Specify:) I certify,under the pains and penalties ofperjarp,that the Information on this application is true and murkier FIRM NAME: ((kc‘N(es Six V6 O✓1 / LIC.NO.: ` ( � S Licensee: Signature /� LIC.NO.:C S t o i TS (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.S6 "73?' O/G( Address: Alt.Tel.No.: ''Per M.G.L.c. 147,s.57-61,security work requires Department 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)0 owner 0 owner's agent. Owner/Agent Signature Telephone No. I PERMIT FEE:$ The Commonwealth of Massachusetts I =:�- i Department ofIndustrial Accidents =_ 1 Congress Street, Suite 100 `�__ Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip:_ Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling — __any capacity.[No-workers'-ccmp,insuranee--required.] 3. I am a homeowner doingall work myself. t 9. ❑Demolition ❑ y [No workers'comp.insurance required.] 4.01 am a homeowner and will be hiring contractors to conduct all work on m • YP roPerh'• I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance? 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *My 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. tContractors 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.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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: am, Phope#: "F 4.-144'i-y.* _ __ . !-i A �," t . y