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HomeMy WebLinkAboutBLDE-21-007272 ECommonwealth of Official Use Only0 Massachusetts Permit No. BLDE-21-007272 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:6/15/2021 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) 15 FAIRWAY RD Owner or Tenant MOORE THOMAS W Telephone No. Owner's Address MOORE EILEEN A, 5 MOUNTAIN SIDE,TOLLAND, CT 06084 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: NC system. 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 Initiatine Devices No.of Ranges No.of Air Cond. 1 Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alertine 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 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 - = Commonwealth of Massachusetts Official Unnly Z� i.= ate t t se =i � RermitNo 'w t,a= Department of Fire Services Occu anc e?_:1_� p y 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: 6/10 (2 City or Town of: Yokain.0 v 4-(A To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform JJthe electrical work described below, Location(Street&Number) 1S rot w (/ � VCU S, Yar � mvr4 Owner or Tenant Tt0.44on) 1 M0,;7 l Telephone No. 0 y 5()G 0 q „ Owner's Address 5 o ii tci(vt 5, , To'T011 a vet, C 1 0 6 y_ 1{ Is this permit in conjunction w ha building permit? Yes n No I C(/(Check Appropriate Box) Purpose of Building ©�Z `, Utility Authorization No. Existing Service Amps •J / Volts Overhead I I Undgrd I I No.of Meters New Service Amps / Volts Overhead[I Undgrd I I No,of Meters Number of Feeders and Ampacity 1 99 Location and Nature of Proposed Electrical'Work: 11 l" I ✓151q l/Gl 1. . G'1 Completion of the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Pans Traa KVATotaToof nsformers KVA No.of Luminaire Outlets No.of Hot Tubs • Generators KVA No.of Luminaires Swimming Pool Above r1 In- r--1 No.of Emergency Lighting grad. I 1 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 TOW Total of AlertingDevices _ No.of Waste Disposers Heat Pump Number Tons I4' Na.of Self Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local) �Munieipal I I Other Connection No.of Dryers Heating Appliances KWSecurity'Systeis:* No.of Devices or Equivalent No.of Water I£W No,of No, of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HPTelecommunications 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 ifs substantial equivalent. The c undersigned certifies that such coverage is In force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ ( p fy:) ❑ OTHER S epi I certify,tinder the pains and penalties ofper•jruy, that the information on this ap lication is true and complete. FIRM NAm E; E.F.WINSLOW PLUMBING &HEATING CO., Ifs .LIC.NO.:3281 C Licensee: RICHARD MELVIN Signature LIC.NO.:2'I829A L../- (If applicable, enter "exempt"in the license number line) B5°8-391-7778Bus.Tel No,: ` - Address; 8 RRARtioN CIRCLE SOUTH YARMOUTH,MA 02664 Alt, el.No,; (�- ` _ *Security System Contractor License required for this work; if applicable,enter the license number here: l k 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 J I owner's agent, ‘ .) Owner/Agent --�- �., Signature Telephone No, PERMIT FEE: $ v- y. E.F. Winslow Inspection Department email: inspections@efwinslow.com The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations a"i; l' Lafayette City Center = s. 0 2 Avenue de Lafayette,Boston,MA 02111-1750 �','.-5�° 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): 1.0 I am a employer with 90 employees (full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.1 I 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. 8. Non-profit [No workers' comp. insurance required] p 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 10.1 I Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4. We are a non-profit orgsni7ation,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. Lie.#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 faun 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 cer ' ylel•the ins and/ penalties ofperjury that the informationprovided above is true and correct. Signature: Y "" (�j,��•ql -~ Date: 01/02/2021 . 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): Li (Board of Health 2.0 Building Department 3.[]City/'Town Clerk 4.El Licensing Board S.[]Selectmen's Office 6.[(Other Contact Person: Phone#: . www.mass.gov/dia