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Home My WebLink AboutBLDE-21-02999 Commonwealth of Official Use Only 6. , E- " • Massachusetts Permit No. BLDE-21-002999 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:11/25/2020 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice ot"his or her intention to pertorm the electrical work described below. Location(Street&Number) 242 ROUTE 28 Owner or Tenant DOUGLIS JOHN Telephone No. Owner's Address C/O GIARDINOS FAMILY RESTAURANT,242 ROUTE 28,WEST YARMOUTH, MA 02673 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appropriate Box) Purpose of Building Commercial 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: Attic furnace replacement 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 ® /d VA No.of Luminaire Outlets No.of Hot Tubs Generator VA No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of , .�_ n••4, i 4to ?� grnd. grnd. Battery �L.� No.of Receptacle Outlets No.of Oil Burners FIRE ALA' ' 0 o(9 0 No.of Switches No.of Gas Burners 1 No.of Detection an' 8 8ip Initiatine Devices Q 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 O Totals: Detection/Alertine Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal 0 Othe 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: KUNG-PO TANG Licensee: Kung-Po Tang Signature LIC.NO.: 21928 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:518 COTUIT RD, MASHPEE MA 026492351 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 pp,,II q�� II Official Use Only �o►nmonweaCth 0//�la�sachuee� _ c-,, �s• R�ri —. Permit No. r i l fl a artmen.t o }ire Serviced Occupancy and Fee Checked �!= hA=f � p j 111'- ? [Rev. 1/07] leave blank) f,115:- BOARD OF FIRE PREVENTION REGULATIONS WORK FOR PERMIT TO PERFORMElectrical�ELECTRICALode 527 CMR 12.00 APPLICATION llwork to be performed in accordance with the ), Z(� TION) Date: IN INK OR T ' ALL INFORVIA To the Inspector of Wires: (PLEASE PRINT r a G�� City oro Town of: 2� gives notice of his or her intention to per arm the electrical work¶escribed below. By this application the undersigned ` ,7� -D 3�3 Z L./ . 4 / r : elephone No. Location(Street&Number) G01 Owner or Tenant . j G"`' ' n �5 I Owner's Address Yes No �� (Check Appropriate Box) PurposeIs this permitf in conjunction with a building permit? Utility Authorization No. ________----- Existing �)�� r YC �� No.of Meters ______ of ry Building Amp —=Volts Overhead❑ Undgrd❑ Service s Undgrd 0 No.of Meters __ Existing Volts Overhead 0 New—=ice �_. Amps --��- Number of Feeders and Ampacityc. , ,i‘ ��a B, / G+ <�L'/� " Location and Nature of proposed Electrical Work: be waived b the Inspector of Wires. Completion o the ollowin.table may Total C No.of Total lJ addle Fans may__Transformers A No.of Ceil: Completion (Paddle)�� No.of Recessed Luminaires Generators No.of Hot Tubs .o.o mergency ig 1 mg No.of Luminaire Outlets Above In- ❑Jib_le Units _— Swimming pool .rnd. ❑ 'rnd. No.of Luminaires ;TIRE ALARMS No.of Zones �� No.of Oil Burners I No.of Detection and No.of Receptacle Outlets No.of Gas Burners If Det in:Devices No.of Switches Total No.of Alerting Devices No.of Air Cond. Tons No.of Self-Contained No.of Ranges Heat Pump Number Tons _.•.. Detectton/Alertin:Devices Totals: Municipal Other No.of Waste Disposers Local❑ Connection Space/Area Heating Security SystemMunicipal * No.of Dishwashers Heating Appliances Ku' No.of Devices or E•uivalent No.of Dryers No.of No.of Data itinNo.of Devices or E uivalent Sins Ballasts No.of Water Telecommunications Whing No.Hydromassag \\,. ..‘ No. I Total HP No.of Devices or E s uivalent Hydromassage Bathtubs No.of Motors .14 OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) C Rule 10,and upon completion. Estimated Value of Electrical Work: erfoEC nce o10,electrical work may issue unless �'�.� 70'1 D Inspections to be requested in accordance with ME Work to Startpermit for the p INSURANCE licensee CE COVERAGE: Unless insurancewthe di owner,"completed verage or office. including operation"ame to the permit issuing substantial equivalent. The the licensee provides that suchf f liabilityove is in force,and has exhibited proof undersigned certifies that cove age ❑ OTHER �] (Specify:) CHECK ONE: INSURANCE location is true and complete. I certify,under the pains and p enalties of perjury,that the information on this app LIC.Npl: . 9/ 28 FIRM NA 1 -�" LIC.NO.: S Z Signatu Bus.Tel.No.: �6 . i D Licensee: O �' Alt.TeL No.: livable,e "exempt"i the license nu .er lin $I,L (If app s r0-1 ``S"License: Te No. Address: Co�d '` Department of Public Safety e normally Per ER'L.c.SU s.5C 61,security work awarees Departm �r owner's a normally INSURANCE WAIVER: I am that the Licensee does not have the liability insurance coverage OWNER'S IN waive this requirement. I am the(check one)❑ required by law. By my signature below,I hereby PERMIT FEE: $ Owner/Agent Telephone No. Signature The Commonwealth of Massachusetts Department of Industrial Accidents •= a � = j - Office of Investigations 41, 600 Washington Street Boston,MA 02111 www.m s.gov/dia Workers' Compensation Insurance Affidavit:sBuilders/Contractors/Electricians/Plumbers u de s/Contractors /Electricians/Plumbers A I licant Information Please Print Le ibl Name (Business/Organization/Individual): Address: City/State/Zip: Are you an employer?Check theappropriate bog: Phone#: T 1.0 I am a employer with 4. [] I am a general contractor and I of project(required): 2.❑ employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8.working for me in any capacity. employees and have workers' . ❑Building addition ❑Demolition [No workers' comp,insurance comp.insurance. 9• required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL 11 ❑Plumbing repairs or additions insurance required.]t c. 152, §1(4),and we have no 12.0 Roof repairs employees. [No workers' 13.0 Other 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 workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 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. Ido hereby certifi,under the pains and penalties of pedury that the information provided above is true and correct Si_i ature: 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/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: