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HomeMy WebLinkAboutBLDE-21-003645 Commonwealth of Official Use Only t1. Massachusetts Permit No. BLDE-21-003645 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:1/4/2021 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) 21 OLD CHURCH ST Owner or Tenant DOBEREINER NIGEL 0 Telephone No. Owner's Address DOBEREINER CATHY A, 15 CLARK RD, FISKDALE, MA 01518 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 Undgrd 0 No.of Meters New Service Amps Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install receptacle for water heater. 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 KVA No.of Luminaires Swimming Pool Abovegrnd. 0 In- ❑ No.of E g ti►'�rk ;ng f grnd. Batte 4 , /Q No.of Receptacle Outlets 1 No.of Oil Burners FIRE ,; R. `�, o es� No.of Switches No.of Gas Burners No.of Detec ,n � 1 y/ Initiating De' 40 .k.....-- No.of Ranges No.of Air Cond. Total No.of Alerting Dev'TonsNo.of Waste Disposers Heat Pump Number Tons KW No.of Self-Containe Totals: I O Detection/Alerting De No.of Dishwashers Space/Area Heating KW Local 0 Municipal d er: 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: 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 @\'A 31(©17-4 OF— OA— c-(4(24Lct __-.\ commonwealth of Massachusetts Official Use Only , * V — / Permit No � �J- `7 S/ � 1= Department of Fire Services 1iOccupancy and Fee Checked • \-,-..„--_-,,, 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(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /2 /Z' /z O City or Town of: %frt?Uh L To the Inspector of Wires: By this application the undersigned give notice of his or her' tendon to perform the electrical work described below. Location(Street&N mber) Z j O/d ( 0<h 3 f _Plina✓ith 1/Q/F dog'2S Owner or Tenant �l I Doiefe/14e✓ /" Telephone No.CjO�� Owner's Address 15 C (ark RrJ r<<Sk c)c l-e A41t di 5 18 5 6 S Is this permit in conjunction with a building permit? Yes ElL No (Check Appropriate Box) Purpose of Building ..\,),A1 rit Utility Authorization No. Existing Service Amps J / Volts Overhead ❑ Undgrd n No.of Meters New Service Amps / Volts Overhead n Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ELec -iI at I Qvt(.e F ror JcJ?f 140.1.1" 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 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 Nom•of DCtCdiu„alai Initiating Devices Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump Number Tons KW No. of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Municipal P Local❑ Connection D'Other No.of Dryers Heating Appliances , Security Systems: _ -- No.of Water No. No.of Devices or Equivalent of No.of Data Wiring: Heaters KW 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: 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 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., INS LIC.NO.:3281C � Licensee: RICHARD MELVIN M Signature ArrAW LIC.NO.:21829A • (If applicable, enter "exempt"in the license number line) N Address: 8 REARDON CIRCLE SOUTH YARMOUTH,MA 02664 Bus.Tel.No.: 508-394-7778 AltTeI f, *Security System Contractor License required for this work;if applicable,enter the license number here: No.: NJ ;- 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)❑owner ❑owner's agent, Owner/Agent Signature Telephone No. I PERMIT FEE: $ I ! - Department of InclusirialAceidents , =AAN .Wipe of Investigations Wil'• '" Lafayette City Center ='''-:-.1, -.72 Avenue de L,fayettex•Bosto/i,)1 022.0 2750 wwr,.rrcaassgov/cltn. Workers' Compensation Insurance Affidavits General Businesses Anplicantxnformatiion Please Print Legibly . 1 Business/Organization Name: E.F.WINSLOW PLUMBING& HEATING CO, INC, • Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone 0:608494;7778 Are you an employer?Check the appropriate box: Business Type(required): 1,0 I am a employer with 90 employees(#Lill and/ 5. '0 Retail or part time)e , 6, 0 Restaurant/Bpr/Eating Establishment 2,0 I am a sole proprietor or partnership and have no 7, 0 Office and/or Sales(incl,real estate,auto,etc.) employees working for me in any capacity. • [No workers'comp.insurance required] 8, 0Non-pro0t 3,0 We are a corporation and its officers have exercised 9. 0 Entertainment , their right of exemption per c, 152,§1(M),and we have 10,0 Manufacturing no employees. No workers' pomp.insurance required]'* i i. ' Veal&Care 4.0 We are a non-profit organization,staffed by volunteers, with no employees. No workers' comp.Insurance req.] 12.0 Other *Any appliaant that checks box#1 mast also fill out the section below showing their workers'compensation policy Information, 'D"If the corporate officers hav,e exempted'themselves,but the corporation has other employees,a workers'oomponsation policy is required and such an organization should pheck box#1, 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Nama:ARROW MUTUAL INSURANCE COMPANY insnrer1a Adtiresc, City/State/Zip: Policy#or Self-Ins,laic.#1909A01/01/2021 Expiration Date; Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date), • Failure to seouri coverage as required under§25.A:of MGL a.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 an'/or one-year imprisonment,as well as civil penalties in the.form of a STOP WO1ti<.OBDBi.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 of Investigations of the DIA for insu'rilnce coverage'verification, 1 do hereby der ' ep the,i a fns and penalties of perjury that the information provided above is true and correct. {�i� `l Signature: �* /�. -.'^ Date: 01/02/2020 -_ Phone#: 608-384.7778 Official use o}aly. Do not write In lids area,to be completed by city or tonin official. . • City or Town: • Permit/License# Issuing Authority(check one); I.OBoardofiXealtli 2,0 Building Department 30 City/TownCiexic 4.D.,icensingBoard 5,0 Seleetmon's Office 6.[(Other Contact Pgrs?n; . • Phone it; www,mass,gov/dia