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Home My WebLink AboutBLDE-21-006029 or 1(7 Commonwealth of Official Use Only ell Massachusetts Permit No. BLDE-21-006029 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:4/20/2021 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) 360 LONG POND DR Owner or Tenant Susan Harrington Telephone No. Owner's Address 360 LONG POND DR, SOUTH YARMOUTH, MA 02664-4243 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check App opriateepx) Purpose of Building Utility Authorization No. n oo Existing Service Amps Volts Overhead 0 Undgrd 0 � ) New Service Amps Volts Overhead 0 Undgrd 0 o ki.,4 e Q Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Permit to close out expired permit. l:) f 4,f,,c,9 ,_ Completion of the following table may be or of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of 1 Transformers ` No.of Luminaire Outlets No.of Hot Tubs Generators No.of Luminaires Swimming Pool Above 0 In- ❑ No.of Emergency Lighting Qrnd. 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 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:) 1 certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: TIMOTHY W MCINTYRE Licensee: Timothy W Mcintyre Signature LIC.NO.: 31437 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address: PO BOX 2428, TEATICKET MA 025362428 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 NirliEettt6(7,/ eg & 1)61) Comth-cRo/u O - Fia vq 48 Ciu-e0 tim TO AROSE Commonwealth of Massachusetts Official Use°� " *t Permit No.l_- 2-k -(4,07-.Y a Department of Fire Services I s Occupancy and Fee Checked -�` BOARD OF FIRE PREVENTION REGULATIONS tRev.9/05] (leavebiank) 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: 11 - //o - , / City or Town of: L r'wlo v` t-\ To the Inspector of Wires: By this application the undersigned Ives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 3(6, j..o vt to,,:,,,-.0( A rty.e • - Owner or Tenant ' S,,SG.,,a l-1 Geri 54-0-,^ Telephone No. ,5D9- '5 '3 Owner's Address ,. .o(O 14,C k s t ax ?,ri I e 1A471, Oao 8 l Is this permit in conjunction with a building permit? Yes No El (Check Appropriate Box) Purpose of Building ' I'eS ceepv-t,<.. ( Utility Authorization No. Existing Service i oe, Amps /le I??c, Volts Overhead❑1_<Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd El No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: .Q .ip ( 1 ni., . C i ,, t 7,4sipP,di c.� 0-i(/ Completion of the followingtable may be waived by the Inspector of Wires. Total No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans T . f TrNo.Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swirr�min Pool Above ❑ In- 0 t o.of Emergency Lighting . 6 g ernd grad. 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 AlertingDevices Tons No.of Waste Disposers Heat Pump Nu _mber•Tons__, KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW . Local 0 Munnectiicipalon ❑ Other, Con No.of Dryers Heating Appliances KW Security Systems:*No. No.of Devices or Equivalent No.of Water KWNo.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 OLliLti: 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 undersigned certifies that such co is rn force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE aBOND 0 O111hR 0 (Specify) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: 7--, no-/-1, ./ ah c-Let VC(,e.c e-r51; LIC.NO.: C 3 I`1 3? Licensee: Signature ?./ LIC.NO.: (If applicable enter"exempt"in the license number tine) Bus.Tel.No.: 2, -8?‘'8�/. 4 Address: Po b c "-V.2.9 -774 ,L/cc7' in c-a.S` Alt.Tel.No.: *Security System Contractor License required for this world;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)0 owner 0 owner's agent. Owner/Agent, Signature Telephone No. PERMIT FEE:$ - I EMAIL ADDRESS: • • The Commonwealth of Massachusetts 3!!. � fl Department of Industrial Accidents 7-3 i5iitE= 1 Congress Street,Suite 100 a. " Boston,MA 02114-2 01 7 •'-,,�,{ ' • •www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(BnsinessfOrganization/tnciividuai): Address: • City/State/Zip: Phone#: • Are you an employer?Check the appropriate box: Type of project(required): LO I am a employer with employees(full and/or pact-tmne).* 7. 0 New construction 2.01 am a sole pmpcietororpartnership and have no employees working for me in 8. 0 Remodeling . any capacity.[No workers'comp.insurance required..) 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No wodcera'comp,insurance required.)t 10[l Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Fiertrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed an the attached sheet 13.ORoof repairs These sub-contractors have employees and have workers'cone.iasurrncax 6.0 We area corporation and itsofficers have exeacisedtheir right of exemption per MGL c. 14.0 Other 152,11(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box4l 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. :Contactors 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 workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: — Policy#or Self-ins.Lie.#: Expiration Date: 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 MGL c.152,§25A is a criminal violation punishable by 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.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 of perjury that the information provided above is true and correct Signature: Date: Phone#: • 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/form Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: