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Home My WebLink AboutBLDE-21-006603 i2k..k ' Commonwealth of official Use Only tE` 1 Massachusetts Permit No. BLDE-21-006603 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:5/14/2021 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) 168 FOREST RD Owner or Tenant MONIZ MICHAEL J Telephone No. Owner's Address MONIZ PHYLLIS B,65 FARNUM RD,WALTHAM, MA 02453 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 100 Amps Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Replacement 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. 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 ❑ 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: 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 6—(1-- A-. 6( '4(21 - T Commonwealth of Massachusetts Official Use Op, --- t X21 _ O5 1.--E-Am Permit No. __��__ Department of Fire Services ^ -F Occupancy and Fee Checked �' _ __ BOARD OF FIRE PREVENTION REGULATIONS �y�-�`�, [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.ININK OR TE ALL INFORMATION) Date: $7 5 /Z I City or Town of: 1 D[[rvi v ffrl To the Inspector of Wires: By this application the undersignedives notice of his or lie(r intention to perform the electrical' work described below. Location(Street&Number) 16 '0/-(5-1- Y kd 5, ' f i 07,6 lj 7 Owner or Tenant r 1,Gi,,A 1 WA V j fyI Telephone No. -1c6( q Z t(o5 ) Y Owner's Address 6C .�dtl/1U1Yl Rd Rkl'WV1 PA 0 1.(1 c 3 Is this permit in conjunction with a building permit? Yes n No (Check Appropriate Box) Purpose of Building (,'t:/L1 Utility Authorization No. Existing Service Amps . / Volts Overhead n 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: i 0 0 fim P ave/tilt dSed!/i ce Completion of the following table may be waived by the Inspector of Wires, No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Toof T Transformers KVA No.of Luminaire Outlets No.of Hot Tubs • Generators KVA Above In- No.ofE-mergency Lighting No.of Luminaires Swimming Pool grad. ❑ grnd. I I 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 Number Tons KW No.of Self-Contained p Totals: "'" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local' I Municipal I I Other Connection No.of Dryers Heating Appliances KWSecuritySyystens:* + No.of Water No,of No,of No.of Devices or Equivalent KW Ballasts Data Wiring: Heaters SignsNo.of Devices or Equivalent tit No.Hydromassage Bathtubs No.of Motors Total RP Telecommunications Wiring: No.of Devices or Equivaent 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 1r. undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. \ CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Speoify:) , ti, n I certify,under the pains and penalties ofperjwy,that the information on this ap ligation is true and complete. FIRM NAME: F.F.WINSLOW PLUMBING & HEATING CO., Ij1 .LIC,NO.:32810 l ..\ \ Licensee: RICHARD MELVIN Signature LIC.NO.:21829A ___) (If applicable, enter exempt"in the license number line) Bus.Tel.No,:50e-3947778 Address: a REARDON CIRCLE SOUTH YARMOUTH,MA 02664 Alt.Tel.No,: *Security System Contractor License required for this work; 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 owner owner's agent, Owner/Agent L' Signature Telephone No. PERMIT FEE: $ ' E.F. Winslow Inspection Department email: inspections@efwinslow.com The Commonwealth of Massachusetts Department of IndustrialAccidents _laOffice of Investigations i : i Lafayette City Center ,it,,z 0 2 Avenue de Lafayette,Boston,MA 02111-1750 ,' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: E.F. WINSLOW PLUMBING &HEATING CO, INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 phone#:508-394-7778 1 Are you an employer? Check the appropriate box: Business Type(required): Oil n I am a employer with 90 employees (full and/ 5. ❑Retail 1 or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.Li I am a sole proprietor or partnership and have no 7• 11 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.[1 We are a corporation and its officers have exercised 9. n Entertainment their right of exemption per c. 152, §1(4), and we have 10.Li Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.Lf We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 Other • *Any applicantthat 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#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic.#1964A Expiration Date:01/01/2022 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to-secure coverage as required under§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 herebycer t /6/......V......— in!and penalties of perjury that the information provided above is true and correct. 01/02/2021 Signature: I° /U Date: Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. • City or Town: Permit/License# Issuing Authority(check one): 1.[jBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board SO Selectmen's Office 6.❑Other Contact Person: Phone#: 1 www.mass.gov/dia