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HomeMy WebLinkAboutBLDE-20-005433 Commonwealth of Official Use Only E ft7Massachusetts Permit No. BLDE-20-005433 ......-' 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:4/15/2020 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 b ow. Location(Street&Number) 7 TRUMAN LN K, (3r i Owner or Tenant SIAMOS JOHN Telephone No. O Owner's Address SIAMOS HELEN, 174 CAPT NOYES RD, SOUTH YARMOUTH, MA 02664 O Is this permit in conjunction with a building permit? Yes 0 No 0 (Check4444r Purpose of Building Utility Authorization No. 0 S Existing Service Amps Volts Overhead 0 Undgrd 0 No.o • •• New Service Amps Volts Overhead 0 Undgrd 0 No.of Meter Able 8)* Number of Feeders and Ampacity iir Location and Nature of Proposed Electrical Work: Power to remote shed. ,,, Gt Completion of the following table maybe wai d tete 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 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:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: RICH M MELVIN Licensee: Rich M Melvin Signature LIC.NO.: 21829 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:8 REARDON CIR, S YARMOUTH MA 026641207 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 J . Signature Telephone No. PE �( t Otki t Y "M. FWD/1Z StteD & 2l- ., (ND Walk, As y'er t p/ c Imo - 14 Commonwealth of Massachusetts Official Use Only .>� ---1-f3 y Department of Fire Services Permit No. Occupancy 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 Cl.527 CMR 12.00 (PLEASE PRINT IN INK OR TYPEALL INFORMATION/) Date: 14 7i� City or Town of: (Jiv ima To the Inspector)of Wires: By this application the undersigned ves notice of his or her intention to perform the electrical work described below. I Location(Street&Number) "1 `f if V Aut,►v l cult{'. VU t 5V y(Ai 1 ' oo A' fl Owner or Tenant I y1 ii/t 6 S i Q GS Telephone No. 5.c4 340 Xy' v) Owner's Address 5L l Is this permit in conjunction with a building permit? Yes ❑ No ✓ (Check Appropriate Box) Purpose of Building V)?.,1'I v G Utility Authorization No. Existing Service Amps / LiVolts Overhead❑ 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: Quip ✓ .* rt.,,vl -e S\- Completion of the following table ntay be waived by the In eeetor of Wires. .ofTotal Cltj No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans T Trr anss KVAformers KVA v, No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires SwimmingPool Above In- No.of Emergency Lighting grad. ❑ grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones "No.of Detection and No.of Switches No.of Gas Burners Initiating Devices f, No.of Ranges No.of Air Cond. Z oonI No.of Alerting Devices � No.of Waste Disposers Heat Pump Number Tones KW No.of Self-Contained Totals: ��" Detection/Alerting Devices .' (1 No.of Dishwashers Space/Area Heating KW Local❑Municipal Connection ❑Other No.of Dryers Heating Appliances KW Security S stems:* 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 desirert 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 0 OTHER 0 (Specify:) I certify,under the pains and penalties of perjury,that the information on this ap )kation is true and complete FIRM NAME: E.F.WINSLOW PLUMBING&HEATING CO., I LIC.NO.:3281C Licensee: RICHARD MELVIN Signature LIC.NO.:21829A (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:8084944778 Address: 8 REARDON CIRCLE SOUTH YARMOUTH,MA 02884 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 inairance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)U owner ❑owner's agent. Owner/Agent Signature Telephone No. I PERMIT FEE:$ The Commonwealth of Massachusetts A . Department of Industrial Accidents Y Si .; Office of Investigations y Lafayette City Center }� z 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 Are you an employer? Check the appropriate box: Business Type(required): 1.© I am a employer with 90 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, ❑ 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. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health 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#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. #1909A Expiration Date:01/01/2021 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 hereby ce ' of the ins and penalties of perjury that the information provided above is true and correct. t .•••+ Date: 01/02/2020 Signature: 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): 1fBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.0Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia