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HomeMy WebLinkAboutBLDE-21-003581 -- '` Official Commonwealth of Use Only Massachusetts Permit No. BLDE-21-003581 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:12/28/2020 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pertorm the electrical work described below. Location(Street&Number) 19 BARKENTINE CIR Owner or Tenant John Villancourt Telephone No. \ Owner's Address Is this permit in conjunction with a building permit? Yes 0 No 0 (Check App ', • e Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 Undgrd 0 .,P. 'f s O New Service Amps Volts Overhead 0 Undgrd 0 No i . /' • e ii,o, Number of Feeders and Ampacity O /Ili? Location and Nature of Proposed Electrical Work: Kitchen renovations(1 Inspection) 0 O Completion of the following table may be waived b v,• , of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Transformers • No.of Luminaire Outlets No.of Hot Tubs Generators t'''- KVA .t No.of Luminaires SwimmingPool Above 0 In- ❑ No.of Emergency igiiting,7. grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARM o.of Zones''i $No.of Detect' n d "6 `u- No.of Switches No.of Gas Burners Initiating D 'ce 2 � Total 7'� ) � No.of Ranges No.of Air Cond. Tons No.of Aler -Devices ,=Y � ©2 7 No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contain /` Totals: Detection/Alerting Devic s. No.of Dishwashers Space/Area Heating KW Local ❑ Municipal 1:1''''-'.;„ \Other:/ Connection „. j ` No.of Dryers Heating Appliances KW Security Systems:* ->,r 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: E F WINSLOW PLUMBING HEATING CO INC Licensee: RICH M MELVIN Signature LIC.NO.: 21829 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:8 REARDON CIRCLE,SOUTH YARMOUTH MA 02664 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:$50.00 Ki A 9( u/z ( 9: ) NOA- 9/' i-"-- ._ commonwealth of Massachusetts Official Use Only Permit No. az-4 3,S123 I 1-EliltM.l _L._ Department of Fire Services 0 =1I- Occupancy and Fee Checked '1/4,7-1---L7BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATIONS Date: /?,7g/20 /Z0 City or Town of: 1 ,vlod{iii To the Inspector of Wires: By this application the undersigned gives notice of his o her intention to perform the electrical work described below. Location(Street&Number) I01 �1a(1({1141 at Ave- ssv Aij Ipt`vnoviii oZC(1 Owner or Tenant ITo 1 t VA l(q v covr4 Telephone No.61 )3356'Wy$ Owner's Address 5) +s'1-bovvvi Ave iljallOolt. /4. 0 1 Is this permit in conjunction with a building permit? Yes El No EF-----(Check Appropriate Box) Purpose of Building i,)AL t/1. Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd n No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity " Location and Nature of Proposed Electrical Work: /c j 71-c/1tciv t�SA9 o vo ran • r Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA • No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- 0 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 DctC�tiun and Initiating Devices No.of Ranges No.of Air Cond. Total No.of AlertingDevices 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 ❑,Other Connection No.of Dryers Heating Appliances KW No'Security oSystems:3' f 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 ifdesired, 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 undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) • I certify,under the pains and penalties of perjury,that the information on this application is true and complete. C'' FIRM NAME: E.F.WINSLOW PLUMBING & HEATING CO., IN Air LIC.NO.: 3281C Licensee: RICHARD MELVIN Signature �A LIC.NO.:21829A • 1 (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.:508-394-7778 Address: 8 REARDON CIRCLE SOUTH YARMOUTH,MA 02684 Alt.Tel.No.: �N -- *Security System Contractor License required for this work;if applicable,enter the license number here: `f:. 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. PERMIT FEE: $ o_..,. Department ofrn1ustrialAecidents ,i at? = .Offtce ofInvesttigatlons „..s+ ,:,,,, �. Lafayette City Center 1'1" 2 Avenue de Zpfltyelie2 Bosioil,MA 02111.1750 �' wwwmass.govldta. • Workelre Compensation XnsuranceAaffidavit: General Businesses Applicant xnformat;ion Please Print Leg:ibI r Business/Organization Name: E.P.WINSLOW PLUMBING&HEATING CO, INC. Address:8 REARDON CIRCLE • City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:608-304.-7778 • Are you an employer?Check the appropriate box: Business Type(required): I 1,0 I am a employer wlth 80 employees(full and/ 5. '0 Retail or parttime).* 6, ❑Restaurant/Bor/Eating Establishment 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. 7. 1::Office and/or Sales(incl,real estate,auto,etc.) Elio workers'comp.insurance required] 8. Ej Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c, 152,§1(0),and we have 10,0 Manufacturing no employees. (No workers' oomp.Insurance required]'r" 4.0 We are a non-profit organization, staffed by volunteers, 11,0eaitli Care with no employees. (No workers' comp.Insurance req.] 12.0 Other ''Any applioant that cheeks 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 plink box#1. I arra an employer that isproviding workers'compensation Insurance for my employees. Below is the policy Information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY ingitrpro C3 AAdrers: City/State/Zip: • • Policy#or Self.ns,Lie,#1909A Expiration Date;01/01/202.1 Attach a copy of the workers' eornpensatio2a policy declaration page(showing the policy number and expjration date). Failure to seouri poverage as required under§25A of MOL o. 152 can lead do the imposition of criminal penalties of a fine up to$1,500.00 anc/or one-year imprisonment,as well as civil penalties In the.form of a STOP WORT<ORDER and a fine of up to $250.00 a day aghinst the violator. Be advised that a copy of this statement may be forwarded to the Office oi'Investigations of the DIA for insu'rilnee coverage Verification, .1 do hereby ter '' !lithe .Ins and penalties ofperJury that the i "ormatlonprovided above is true and correct, ianature; , r14.4f--,, 44.4.,4‘...,- 01/02/2020 0 Phone#; 608-3847778 Official use oily. Do not write In this area,to be completed by city or tonin zfcial. • City or Town:, • Permit/License# Issuing Authority(check one); 1.DBoard of irealth 2,0 Building Department 3.0 City/Town Cleric 4.0Y.Jicensing Board • 5.Dgeleetmon's Office 6.[[Othiei• Contact Pgrspn: • Phone 0; www,mass,gov/dia • 1 i