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Home My WebLink AboutBLDE-21-006464 t�� Commonwealth of Official Use Only Massachusetts Permit No. BLDE-21-006464 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:5/7/2021 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) 8 SEASIDE VILLAGE RD Owner or Tenant ADAM AN ELLEN RATAJ Telephone No. Owner's Address 8 SEASIDE VILLAGE ROAD, SOUTH YARMOUTH, MA 02664 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 ❑ 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: New residence. 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/Alertine Devices No.of Dishwashers Space/Area Heating KW Local ❑ 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: Jack W Griffin Licensee: Jack W Griffin Signature LIC.NO.: 418 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:26 JOANNA DR,S YARMOUTH MA 026641339 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: $180.00 c ( 3 /ltfc( -c gt +arr 7/ ( i ' NA-C . 'VW(u ' CommonaysanA.o/ri7aMaehusstis Official Use Only 75, �` ' Permit No.V'P q to`® 1= 2spariited ol.}irs Servcrs (f i Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. (leave blank) Qj APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code E ),527 CMR 12.00 I (PLEASE PRINT IN INK OR TYPE ALL INF MATION) Date: S 01/ City or Town of: yiken,ad To the Inspector of Wires: By this application the undersignves notice of his or her intention to perform the electrical work described below. Location(Street&Number) 0 SCA g;64 V 1 1/#41-e., 1e)7 Owner or Tenant RZW/k( r I l/eA) RA+As Telephone No. Owner's Address Is this permit in conjunction with a buik4ing permit? Yes No El (Check Appropriate Box) Purpose of Building girlie() 4-4m11.1 %ej v.•-ir- Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undg;,,j[1 No.of Meters New Service ?AO Amps /2e) 1024O Volts Overhead E1Undgrd ler No.of Meters / Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: tvA66. 4bucc. G rit reaz Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp. Tof T (Paddle)Fans Traa onsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires SwimmingAbove In- No.of Emergency Lighting Pool grad. ❑ grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of No.of Switches No.of Gas Burners No. Initiatinnggon Deteand InDevices 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 al❑ Municipal 1--, Other, Connection No.of Dryers Heating Appliances KW Securis:* No. f Devices or Equivalent No.of Water , No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsNo.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value o Electrical Work: (When required by municipal policy.) Work to Starr 7 02 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE RAGE: 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 cov ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER 0 (Specify:) I certify, under the pains and pe es of perjury,that the information on this application is true and complete. ,/ FIRM NAME:: n� LIC.NO.:�F 7/T 6j Licensee: .lack, r t Signature LIC.NO.4-dS-49l9 (If applicable,enter�empt"in the li ense nu►ry�r line.) / Bus.TeL No.: 977 `/7 9 vSa 1 Address: c24 Jo l4 tJN04 V K J j4iCI'Ylevt4 ,4V 9 Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work refres Department 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 PERMIT FEE: S Signature Telephone No. The Commonwealth of Massachusetts _.: j' Department of Industrial Accidents L ;111-- 1 Congress Street, Suite 100 t Boston, MA 02114-2017 \-14-.711 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibl'y Name (Business/Organization/Individual): Address: J ,J//a City/State/Zip: J 00144q Phone #: 97-79 Are you an employer?Check the appropriate box: Type o 'ect(required): 1. 1-i am a employer with I employees OP d/or part-time).* 7• ffl N. construction 2.❑I am a sole proprietor or partnership and ham no employees working for me in 8. ❑ ' modeling any capacity.[No workers'comp.insurance required.) 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my PPerty.ro I will I O .wilding addition ensure that all contractors either have workers'compensation insurance or are sole 11./4 Electrical repairs or additions proprietors with no employees. 12./Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 .❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 4 ❑Other Gvyire 11014,- - 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensatio, policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside . •• . must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contrac •. and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy n . I am an employer that is providing workers'compensation insurance for my loyees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address S A .Sid. V t l 1' iC-iO City/State/Zip: S0474OV1� 14460467 Attach a copy of the workers' compensation policy declarati ' page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c, 152, § ;A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties , i e form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th 'nd pen, a' of perjury that the information provided above is true and correct. Signature: Date: s�6/2/ 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#: