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Home My WebLink AboutBLDE-21-001615 Commonwealth of Official Use Only ' . E. � � Massachusetts Permit No. BLDE-21-001615 - 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:9/28/2020 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) 41 PARKWOOD RD Owner or Tenant FAN JERRY Telephone No. Owner's Address FAN KIMBERLY, 27 SETTLERS LN, COLCHESTER, CT 06415 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appry she Box)r1 Purpose of Building Utility Authorization No. /�,�44, 2.3 Existing Service Amps Volts Overhead 0 Undgrd ❑ of 4New Service Amps Volts Overhead ❑ Undgrd ❑ o. �A]� Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Bond wire to piping. Po,Q,2 D:;• Completion of the following table may be waived . . • Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of 1$ 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 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 0 Municipal ❑ 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 Signs 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 Commonwealth of Massachusetts Official Use Onty. -� 1 21-, , Permit No. _` 0 = Department of.Fire Services IBOARD OF FIRE PREVENTION REGULATIONS Occupancy and lee Checked [Rev.9/05] (leave blank) ' APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All Work to be performed in accordance with the Massachusetts Eldotrical Code(MBC),527 CMR 12.00 (PLEASE PRINT IN INK OR TI'PEALL INFORMATION) Date: /9/Z '/ZO City or Town of: Yd, 'yj pc/11-(n To the Inspector of Wires: By this application the undersigned gives Notice of his or her'-----"--t to,perform the electrical work described below. Location(Street&Number) i{ 1 pot/A-wood Rd 5 Nth h'1 ra61/pi/ 026'6 V Owner or Tenant ki al Nil Owner's Address 15 3 R a in Ovid HS AV-held-6(ci C t Q 6'`o Telephone No. G Q9/y 7-2q Is this permit In conjunction with a building permit? Yes ❑ Appropriate M"---(Check A rop trate Box) Purpose of Building b waif" Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd g ❑ No.of Miters New Service Amps / Volts Overhead❑ Undgrd Number of Feeders and Ampacity ❑ No.of Meters Location and Nature of Proposed Electrical Work: NA d wire - (A(4 7 . . t • Colnpletlon'of thefpllowingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Weddle)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 • t;rfd• ❑ grnd. ❑ 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 No.of RangesTotal _ �riitiirtinK DevicesNb.of Air Cond. • Tons No.of Alerting Devices No.of Waste Disposers Heat Pump I Number (Tons 1 KW No.of Self-Contained Totals: "'"""" I" i Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local Municipal ❑Connection• ❑Other No.of Dryers Heating Appliances KW Security'S stems• y ,* • No.of Water No,of No.of Devices or Equivalent Heaters KWNo:-of Data Wiring: i Signs Ballasts . No.of Devices or E41Nlvalent No.Hydromassage Bathtubs No.of Motors Total HP • Telecommunications yW(trrmg; OTHER: • No.of Devices or Equivalent • i Estimated Value of Electrical Work; (When additional deal'(fdes red,or as required by*inspector of Wires. (When required by municipal policy.) Work to Start: Inspections to be requested.iit 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 121 BOND 0 OTHER 0 (Specify:) I certify,under tire pains and penalties of per;jury,•that the Information: I5h1catb0n is true and complete. FIRM NAME: E.F.WINSLOW PLUMBING&HEATING CO., I N Licensee: RICHARD MELVIN LIC.NO.: 81 C Signature 21 LTC.NO.;21829A "--c. {(f'appJTcable,enter "exempt"in the license nrrmbsr'lTrie.) (~ Address: a REARDON CIRCLE SOUTH YARMOUTH,MA 026e4 Bus.Tel.No.;508.3944778 Alt J *Security System Contractor License required for this work;if applicable,enter the license number here:Ntr;,: Nj INN OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have'the liability Ma rance coverage normally ' _ required by law. By my signature below,I hereby waive this requirement. I am the(check one)Downer ;Downer's agent. Owner/Agent Signature Telephone No. 1 PERMIT FEE:$ • I., • A. The Commonwealth of Massachusetts , _, jr...F....L.5i—.i Department oflndustrialAccidents • •Office ofInvestigations a�E`_. •7' Lafayette City Center 2 Avenue de Lafayette,Boston,MA D.2.111-17.50 ri: ' www..mass gov/dia •Workers' Compensation Insurance Affidavit: General Businesses A licant,Information • Please Print Le•ibl Business/Organization Name: E.F. WINSLOW PLUMBING& HEATING CO, INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-39477778 Are you an employer?Check the appropriate box: 1.1:: I am a em to ex with 90 Business Type(required): p y employees(full and/ 5• 0 Retail or part-time).* 2.CII am a sole proprietor or partnership and have no 6. ❑Restaurant/Bar/Eating Establishment T Office and/or Sales,(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. EI Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have no employees. [No workers' comp. insurance required]** 10'0 Manufacturing 4.E] We are a non-profit organization,staffed by volunteers, 11 0 Health 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. **]f 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.Lic.#1909A Expiration Attach a copy of the workers' compensation policy declaration page(showing the policyllate:numba ) er nd0expiration date . Failure to secure coverage as.required under§25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 uup p 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 '. of the ins andpenalties o ,F/ of perjury that the information provided above is true and correct i nature: , r •�* ,....4 01/02/2020 Date: Phone th 508-394-7778 Official use(Ally. Do not write in this area,to be completed by city or toren official City or Town: ' Permit/License# Issuing Authority(check one): 1.DBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.[]Other • Contact Person: Phone#' . www.mass•gov/dia • • I I