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Home My WebLink AboutBLDE-22-003796 o' Commonwealth of Official Use Only sig 0Massachusetts Permit No. BLDE-22-003796 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.l/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:1/7/2022 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) 13 DIANE AVE Owner or Tenant JANEK ROBERT J Telephone No. Owner's Address JANEK ELIZABETH A, 13 DIANE AVE, SOUTH YARMOUTH, MA 02664 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: Kitchen remodel ,washer, &dryer. 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 Initiatine Devices No.of Ranges No.of Air Cond. TTotal No.of Alerting Devices n 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 ❑ Other: Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Eauivalent No.of Water KW No.of No.of Ballasts Data Wiring: Heaters Siens No.of Devices or Eauivalent 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:) 7&y 419_.ZSR 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 my signature below,I hereby waive this requirement.I am the(check one) 0 owner 0 owner's agent. Owner/Agent Signature Telephone No. PERM EE:$50.00 411.111.176) aj 40--att (((Lf IV/r Atztoutile (--4..a 04-a) q,,,,,, . l 7 zV l Com onwea of Mamaclumetts Official Use Only Permit No. E2-2----3796::-.7 " Y=vi...--;, apartment o� ire Services fr; Occupancy and Fee Checked ,' BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] • ..>- „i (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code. C), 27 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFOR TION) Date: .;! 5 c 9N-. City /'l /y/0 v To the 1 ect r ofWires: or Town of: p By this application the undersign gives notice of,Jis or her inion to perform the electrical work described below. Location(Street&Number) 'D19 Ni AA/\r( Owner or Tenant i ,6 f V.-4N Telephone No. Owner's Address 544.2.— Is this permit in conjunctio with a building permit? Yes ❑ No 0 (Check Appropriate Box) Purpose of Building / 4,0%y„.,111 he,✓S-P_.. - Utility Authorization No. Existing Service/00 Amps /20/a t/e2Volts Overhead❑ Undgrd❑ No.of Meters / New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampaeity ) Location and Nature of Proposed Electrical Work: fr/7'��moi') dyt 476.--e_, -71- (j 146 f'11t�, .may' -P!� cc// Completion of the followr'ntable nw be waived by the Inspector of Wires. o,of Total No.of Recessed Luminaires No.of CeIL-Soap.(Paddle)Fans Tratfaformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires SwimmingPool Above ❑ In- ❑ No.at i•:mergency Lighting rend. grad, Battery Units No.of Receptacle Outlets No.of OB Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners -No.InDeteg Dn and IitlatintaDevices Total 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 Totals: Detection/AlertmgDevlces No.of Dishwashers Space/Area Heating KW Local 0 Confection 0 Other No.of Dryers Heating Appliances KW Si :o,of s� r Equivalent No.of Water , No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP T of Devices oommunireadar Eq ant OTHER: Attach additional detail if desire4 or as required by the Inspector of Wires. Estimated Value f E trical Work: (When required by municipal policy.) Work to Start:/ 02 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 liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov ge 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 a penalties ,that the information on this application is true and complete,. �pp (//(~ FIRM NAME: J t3 1± i v< LIC.NO. Y ` V bb Licensee: � � Gr 1 c ,/v Signature LIC.NO.: C," (7/9. (If applicable, mer�a mp�t"in the lie e n 1' l Bus.TeL No.:4 7E-5/7F-off.-pZ, Address: 00 �.JO''�"•1)1 i4� �A�2 k10 0, oe)� y Alt.TeL No.: *Per M.G.L.c. 147,s.57-61,security work rem'. Department of Publi 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 Signature Telephone No. PERMIT FEE:.$ The Commonwealth of Massachusetts ►"_ , ,_!L Department of Industrial Accidents ?dnl= 11 Congress Street, Suite 100 'SIT= " Boston, MA 02114-2017 -r ,. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information nn n Please Print Legibly Name (Business/Organization/Individual): —Tete,//�� r.'/r.- 'C Address: c �o)04QN A V r— City/State/Zip: ,c (lye f 7&UJ /46 O '1 hone#: 9 '/792S) / Are yo an employer?Check the appropriate bo / Type of project(required): l.Iaam a employer with / employ .nd/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.) 8. Remodeling 3.01 am a homeowner doing all work myself.[No workers'comp.insurance -..' -.]t 9 ❑Demolition 10 0 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on . property. I will ensure that all contractors either have workers'compensation . • 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-co»rs '•• • on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'«, p.ins •t 6.0 We are a corporation and its officers have exercised• right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers' .„ •.insurance required.] *Any applicant that checks box#1 must also fill out the ;on below showing their workers'compensation policy information_ t Homeowners who submit this affidavit indicating' are doing all work and then hire outside contactors must submit a new affidavit indicating such. *Contractors that check this box must attached an . 'onai sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have empi• they must provide their workers'comp.policy number. I am an employer that is p , : orkers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. /Lie.#• Expiration Date: Job Site Address: / i l//,4N"c-d Ail 1\v-e-- City/State/Zip:S q 0-Oft MO 606 y Attach a copy of th workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure 'average as required under MOL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year' prisonment,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 iolator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage yeti' ::on. I do hereby a fy rind- e ,,, -nd penalties of perjury that the information provided above is true and correct. Signature: Date: //t5oC 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: Phone#: