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HomeMy WebLinkAboutBLDE-20-005811 227 PINE ST Commonwealth of Official Use Only Permit No. BLDE-20-005811 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:5/14/2020 City or Town of: YARMOUTH To the Inspector of Wires: c 3G Z—4/73 22 By this application the undersigned gives notice of his or her intention to pertorm the clectrr al w describe. .w. Location(Street&Number) GREENOUGHS POND . .�y x'-- ;,;t Owner or Tenant CAPE COD COUNCIL OF B S A C ,ji.�ej s an-gc Telephone No. Owner's Address 247 WILLOW ST,YARMOUTH PORT, MA 02675-1744 /� is this permit in conjunction with a building permit? Yes 0 No 0 (Check Approp "' r Purpose of Building Utility Authorization No. 23 Existing Service Amps Volts Overhead 0 Undgrd 0 Sr •f r d New Service Amps Volts Overhead 0 Undgrd 0 No. i1kl t. © ' ,m'cm Number of Feeders and Ampacity VVV r, Location and Nature of Proposed Electrical Work: Replacement furnace. 0 Completion of the,following table may be waived by t b. Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Transformers K No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above 0 in- CINo.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/Alerting 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 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: $80.00 0 A e(co/U' l A . Commonwealth of Massachusetts Official Use Only / " ft Permit No, �9� C l =� __„iDepartment of Fire Services '(-f Occupancy and Fee Checked , =b' 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 C),527 CMR 12.00 (PLEASE PRINT LV INK OR TYPE ALL 1WFORMATIOI) Date: L1 � /ZO City or Town of: \(a f To the Inspector of Wires: By this application the undersigned gives notice of his or her in ention to perform the electrical work described below. Location(Street&Number) w-� P•,, # cjwic 11 I-in Pouf 0`E 1 S `' i 61071 Owner or Tenant Ail lt95 CO(/'v� Telephone No. Wje7. 7,:2-6 0 vu Owner's Address ,, : Z ) a : . 7i (1v26C(1 Is this permit in conjunction witl a building permit? Yes ❑ No Li (Check Appropriate Box) Purpose of Building p W QC 1(V((a Utility Authorization No. Existing Service Amps J / Volts Overhead❑ Undgrd❑ No.of Meters New-Servlee — Amps -.-_-•-___-/_---.__--Volts--__-Overhead-❑_.___...Undgrd-❑__._.---No:of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: rt�(�G't(e ft4 5'7 117 CA Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of.Ceil.-Susp.(Paddle)Fans Tof T Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- 19o.of Emergency Lighting No.of Luminaires Swimming Pool 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/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ConnectMunicipal ion ❑ Other No.of Dryers Heating Appliances KW Security Systems:' No.of Water No.of No.of No.of Devices or Equivalent KWBallasts Data Wiring: Heaters Signs No.of Devices or Equivalent No.hydromassage Bathtubs No.of otors Total HP Telecommunications Wiring: Motors 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: 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 -- - ---under-signed-eertifies-that-such-coverage-is-in-force,and has exhibited-proof crf same to-the-permit-issuing office. —- CHECK ONE: INSURANCE ® BOND 0 OTHER 0 (Specify:) . I certify,under the pains and penalties of perjury,that the information on this ap lication is true and complete. z ,,p FIRM NAME: E.F.WINSLOW PLUMBING&HEATING CO., IDI .LIC.NO.:3281C '\)'' Licensee: RICHARD MELVIN Signature LIC,NO.:21829A cJ C/) (If applicable,enter"exempt"in the license number line) Bus.Tel.No.:508-394-7778 ‘ -D- Address: 8 REARDON CIRCLE SOUTH YARMOUTH,MA 02664 Alt.Tel.No.: .J *Security System Contractor License required for this work;if applicable,enter the license number here: 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)Downer J n,owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ • N • The Commonwealth of Massachusetts li Department of IndustrialAccidents ( ,IIIIMIE: I Office of Investigations .,la 01:7 Lafayette City Center 2 Avenue de Lafayette,Boston,MA 02111-1750 ..11.,,- '41‘111r‘ 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##:508-3g4-777 Are you an employer?Check the appropriate box: Business Type(required): 1.11 I am a employer with90 employees (full and/ 5• ❑Retail orpart-timer- 2. art=tune):* — _ ----- .____ 2.0 I am a sole proprietor or partnership and have no 6. ❑Restaurant/Bar/Eating Establishment 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. Non-profit 3.LI We are a corporation and its officers have exercised_ 9.. their right of exemption per C. 152,§1(4),and we have Entertainment__.. _...__._._ .._._ __ _ 10.0 Manufacturing no employees. [No workers' comp.insurance required]** 4.0 We are a non-profit organization,staffed by volunteers, 11.10 Health Care with no employees. [No workers' comp.insurance req.] 12.0 Other *My 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.Lic.#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 MGL 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 ' e1 the 'ins andpenalties o ,¢/ f penury that the information provided above is true and correct. Signature:. __ --_}d -,, ......oh.-.. 01702/2020 Date: Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. City or Town: . Permit/License# Issuing Authority(check one): 1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.DLicensing Board 5.E Selectmen's Office 6.0Other 1 1 Contact Person: Phone#: i www.mass.gov/dia