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HomeMy WebLinkAboutBLDE-22-000208 Commonwealth of Official Use Only \% Massachusetts Permit No. BLDE-22-000208 Co BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.1/071 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:7/13/2021 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 22 DUTCHLAND DR Owner or Tenant PAULDING ROBERT Telephone No. Owner's Address PAULDING NANCY,22 DUTCHLAND DR,YARMOUTH PORT, MA 02675-2415 aul -, J Is this permit in conjunction with a building permit? Yes 0 No 0 (C 'B#) !<-ll Purpose of Building Utility Authorization ,;:zi M �' ctuiQet' Existing Service 100 Amps Volts Overhead 0 Undgrd ■ . New Service 200 Amps Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Upgrade service 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 No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Ton l No.of Alerting Devices 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 Eauivalent No.of Water KW No.of No.of Ballasts Data Wiring: Heaters Signs No.of Devices or Eauivalent 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: David W Grippen Licensee: David W Grippen Signature LIC.NO.: 38409 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:PO BOX 284, BRIDGEWATER MA 023240284 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 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: $50.00 S r2 r /feet", Gjou o/i [� E v G , * l�oirtmonwea 01 Ma�ac� Official Use Only 'hew .t Permit No. �DZ--O ��g �'��Ll 1 =- k, 2epa tm4nt o` ire spiced 'u ` `1 Occupancy and Fee Checked '�� :OARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) ,,,, - -- All APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ev All work to be performed in accordance with the Massachusetts Electrical Code(MEC),57 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: J'//Q/�, City or Town of: YarmouQ�� ort To the Inspector of Wires: By this application the undersigned gives notice of his Yrher intention to perform the electrical work described below. Location(Street&Number) aa.... D c 4 fad dl" Owner or Tenant By b S(.1p kH 9 `` Telephone No. —6("5-ff,�. Owner's Address So Vvii 05 Q A%)e Is this permit in conjunctionwitha building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building ,Si tie c i/r/7 P/,�e//l pj Utility Authorization No. 6 /5- 7056 Existing Service (% AmpsVV / / 02 4/61 Volts ✓Overhead © Undgrd❑ No.of Meters / New Service go° Amps a /,R4/0 Volts Overhead y_/ Undgrd ❑ No.of Meters 1 Number of Feeders and Ampacity Seroie e, C,p 4 Beit' doe_ 741 �'OIhA slier /Se# Location and Nature of Proposed Electrical Work: (/V (/ Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Tof T 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 No. InDeteand Initiatinnggon Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices 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 Municipal ❑ Other Connection No.of Dryers Heating Appliances KW '8ecurity Systems:* No.of Devices or Equivalent No.of WaterKms, 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 ofpet ical Work: 36/0d (When required by municipal policy.) Work to Start: 7//Dia f 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. FIRM NAME: �A'vF Gr lark, ,�/Pc rS�/CiCh LIC.NO.: ,F3905" Licensee: t Gro, , _, Signature /4,l/fir LIC.NO.: C (If applicable,enter"eem,` in the l' e e umber ne.) f Bus.Tel.No.: .SQI(''/15/ Address: e•A- 0 1/ o!"c�<fr ei.w., — 274 Qp? % Alt.Tel.No.: S 3:3k *Per M.G.L.c. 147,s.57-61,security work require epartment 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)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents 71-1.711„ 1 Congress Street,Suite 100 Boston,MA 02114-2017 '.r� ��E www mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lesibly Business/Organization Name: Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. 0 Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ 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. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp. insurance required]** l LEI Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees.[No workers'comp.insurance req.] 12.0 Other *Any applicant that checks 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 check box#I. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: 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 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/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia