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Home My WebLink AboutBLDE-21-001654 d r 1 ' /CommonweaIth Official Use onlyIfil of Massachusetts Permit No. BLDE-21-001654 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:10/1/2020 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) 32 MASSACHUSETTS AVE Owner or Tenant BRIAN TOMOLONIS Telephone No. _ Owner's Address 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: Replacement furnace. 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 1 No.of Detection and Initiatinc 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:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: RICH M MELVIN Licensee: Rich M Melvin Signature LIC.NO.: 21829 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:8 REARDON CIR,S YARMOUTH MA 026641207 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 bqp-`t(t011-0 1--C3`-. 64 [ K4/ . 2/!e(z ii OVA_ 513( (L/d r-tAm) A Commonwealth of Massachusetts of nialuseonly '� �� -/2-....C. P' el 4 Department of Fire Services Permit No. �0Occupancy and Poe Checked ----- . ;.•'s BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All Work to be performed in'accordance with the Massachusetts Electrical Code (PLEASE PRINT WINK OR TYPE ALL INFORMATIO� Date: / / /20 N•527 CMR 12.00 City or Town of: )'q(i'j1 ��,.� � 7 By this application the undersigned gives`noticel of his or her int ntion to perform the To the Ielleectr cal ectorw described below. Location(Street&Number) 2 qSCa(� se 5 ✓e Aj i lJ a rrn 01/01 Owner or Tenant g((Q1 0/no 0� `- Owner's Address I l A 601 fon a,iv,L MA 0?1 l Telephone No._Gl ) �/3$11(' 7 Is this permit in conjun on ith a building permit? Yesr-� � Purpose of Building �,U�l,4! 0 No l� (Check Apprs;:,•late Box) Utility Authorization No. • Existing Service Amps J / Volts Overhead 0 Undgrd❑ No.of Meters New Service Amps / Volts Overhead El Number of Feeders and Ampacity Undgrd❑ No.of Meters Location and Nature of Proposed Electrical Work: • Comoletlon'of'ihe fpllowtng.bible nuns be waived by the Ins•eotor of Wires. No.of Recessed Luminaires No.of Cei1.-Susp.(Pa'ddle)Fans No.b Total No.of Luminaire Outlets Transformers , . KVA No.of Hot Tubs Generators • KVA No.of Luminaires Swimming Pool Above In- No.of Lmergency Lighting i;1'rid. ❑ grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE • •ALARMS Ilio,of Zones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges Total Initiating Devices Nb.of Air Cond. • Tons No.of Alerting Devices No.of Waste Disposers Heat Pump I Number (Tons" K'V}� No.of Self-Contained Totals: f """�" """"`""" Detection/Alerting Devices No.of Dishwashers Space/Area Heating ICW Local Municipal No.of Dryers Connection 0 Other ry Heating Appliances KW Security'Systems:* No.of Wa r KW No.of No.of No.of Devices or Equivalent HeatersSi:ns Ballasts •Data'V Wiring: No.Hydromassage Bathtubs No.of Devices or ` ; valent g No.of Motors Total Hp . e ecommun ca ons i" r ng: OTHER: • o.of Devices or E. *valent • Estimated Valtte of Blectrical Work: Altadh additional detail T desired,or as required by the•Inspector qf Wires. S Woto d Va; (When required by munioipal policy.) inuested.in r INSURANCE COVERAGE: Unless waived by the owner,no permit for the perfance with ormance mance of electrical work may e 10.and upon ytiss, �• the licensee provides proof of liability insurance including"completed operation"coverage or its substantial•equi alente The unless 1. undersigned certifies that such coverage Is In force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCl3 ® BOND 0 OTHER I cer0 (Specify:) certify,under the pains and penalties ofpe,gury,that the Information on this a..lication Is true and complete FIRM NAME: E.F.WINSLOW PLUMBING&HEATING CO., i • Licensee: RICHARD MELVIN ••LIC.NO.:3281C ((/'applicable,enter "exempt"in the license numberiine.) Signature _liarLIC.NO.:21829A Address: 8 REARDON CIRCLE SOUTH YARMOUTH.MA 02884 Bus.Tel.No.s 84.7778 *Security System Contractor License required for this work;if applicable,enter the license number here: Alt.Tel.No.:'608 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have The liability in urance cov age normally ' required by law. By my signature below,I hereby waive this requirement. I am the(check one e owner owner's a ent. Signature Telephone No. PERMIT F E.$ 1014•• 4 ' • The Commonwealth of Massachusetts Department of Industrial Accidents I =w-- . 1=z' pp .Office of Investigations ,`_"1;.— ±I Lafayette City Center "-:�{ 2 Avenue de Lafayette,Boston,MA 02111-1750 ":'z"'. 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. 0 Retail 2.❑ or pazt time).* 6. ❑Restaurant/Bar/Eating Establishment I am a sole proprietor or partnership and have no employees working for me in any capacity. 7. 0 Office and/or Sales (incl.real estate,auto,etc.) [No workers' comp. insurance required] 0. ❑Non-profit 3.❑ 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.❑ We are a non-profit organization, staffed by volunteers, 11.[]'}teeth Care with no employees. [No workers' comp.insurance req.] 12.0 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. Lie.#1909A Expiration Date:01/01/2021 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 cer a the ins and penalties of perjury that the information provided above is'true and correct. Signature: , 7y /i�..,.,�l.•-..-• Date:_ 01/02/2020 Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town Vida City or Town: Permit/License# Issuing Authority(check one): 1.0Board of Health 2.0 Building Department 3.0 Clty/Town Clerk 4.El Licensing Board 50 Selectmen's Office 6.0Other Contact Person: . Phone#: www.mass.gov/dia