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BLDE-20-006236
r i''' or ttu - ,.,� 'O'.• •A Commonwealth of Official Use Only Permit No. BLDE-20-006236 �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:6/16/2020 City or Town of: YARMOUTH To the Inspector of Wir s: By this application the undersigned gives notice of his or her intention to pertorm the electrical work described below. e) Location(Street&Number) 37 MOSS RD LJ :� Owner or Tenant FINNERTY PAULETTE TR(EST OF) Telephone No. Owner's Address PAULETTE FINNERTY REV TRUST, 110 BLACK OAK RD,WESTON, MA 02493 O p Is this permit in conjunction with a building permit? Yes 0 No 0 (Check o' +P' ' 11 Purpose of Building Utility Authorization No. Po Existing Service Amps Volts Overhead 0 Undgrd 0 No.of Me rs 43/1/8 New Service Amps Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install generator. q(i)) 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 1 KVA 22 No.of Luminaires Swimming Pool Above ❑ In- 1:1No.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. 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: ANDREW M LEVESQUE Licensee: Andrew M Levesque Signature LIC.NO.: 17318 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:461 LOWER COUNTY RD, HARWICH PORT MA 026461831 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 NOg 1la(z4 m Commonwealth o/Namachraeeita Official�ciUse Only R= — t c� Permit No.e c-� LZ3 = 1_ .2Jeloartment of ire�eruiced `t.;_=tf=6 Occupancy and Fee Checked \� BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank) APPLICATION FOR PERMIT TO PEI'ORM ELECTRICAL WORK MI work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR12.002.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: (,0I t �v City or Town of: C t"t H- To the Inspe for o sires: By this application the undersigned"Ir`mves notice of his or her intention to perform the electrical work described below. Location(Street&Number) áÁ/i -S MD Owner or Tenant.J 0 T l l .. 0( Telephone No. Owner's Address Is this permit in conjunction�y with a building ermit? Yes liJ No ❑ (Check Appropriate Box) Purpose of Building�h IZ, Yl __ t ,Utility Authorization No. Existing Service . .1 t/ Amps i'L Ul�()Volts Overhead❑ Undgrd2 No.of Meters I New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: W I R.I N& ©r ?.,�--1'<4A/ (P 1O Ie_ Completion of thefollowinptable may be waived by the Inspector ofW ares. 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 Pool Above Iu- No.of Emergency Lighting No.of Luminaires Swimmin g mid. LJ grrnd. ❑ 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. Ton Tons No.of Alerting Devices No.of Waste Disposers Heat ramp Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local 0 Conneeeti n 0 Other No.of Dryers Healing Appliances r 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: R7}� Attach additional detail(fdeaire4 or as required by the Inspector of Wires. Estimated Value of ectdcal Work: U U v (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE C GE: 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 IN BOND 0 OTHER 0 (Specify:) I cera;fy,under thepains and penalties of perjury,that the information on this application is true and complete. FIRM NAME:Harwich Port Heating &Cooling, LLC . LiC.NO.:17318A Licensee:Andrew Levesque Signature i �L� LIC.No.35976E (If applicable,enter"exempt"in the license number line.) Bus.TeL No;508432-3959 Address: 461 Lower County Rd, Harwich Port, MA O2040 . Alt.TeL No.: *Per M.G.L.c.147,s.57-61,security work requires Department of Public 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)0 owner ❑owner's agent. Signature eIIt Telephone No. PERMIT FEE:$ k 0 ** Please fax a copy back to us at 508-430=6075 ** or e-mail to: keciaahphcllc.com 43(40G02- The Commonwealth of Massachusetts T,,, .. Department of Industrial.Accidents 4" Office of Investigations �--,i 600 Washington Street 4 • .--moi' ,_ 01.--..,-; k.- Boston,MA 02111 www.mass.gov/dia , Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Harwich Port Heating & Cooling LLC Address: 461 Lower County Road • City/State/Zip: Harwich Port MA 02646 Phone#: 508-432-3959, Are you an employer?Check the appropriate box: Type of project(required): 1.12 I am a employer with 75 4. ❑ I am a general contractor and I employees(full and/or part-time).* _ have hired the sub-contractors 6. P New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. g Remodeling ship and have no employees. These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp.insurance comp.insurance. required.]- • 5. ❑ We are a corporation and its 10.g Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.g Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.[ Other HVAC employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing worker's'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Selective Insurance Company of South Carolina Policy#or Self-ins.Lic.#: WC9059813 Expiration Date: 10/26/2020 Job Site Address: • City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 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 certify under the pains and penalties ofperjuary that the information provided above is true and correct. Signature: Date: Phone#: 508-432-3959 - 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#: