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Home My WebLink AboutBLDE-22-000924 Commonwealth of Official Use Only A. Massachusetts Permit No. BLDE-22-000924 4.... 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:8/18/2021 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) 113 WILFIN RD Owner or Tenant HERTZBERG RICHARD E JR Telephone No. Owner's Address HERTZBERG IRENE, 3 EAGLES NEST WAY UNIT 321, FRANKLIN, MA 02038 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: Replacement HVAC 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 1 No.of Detection and Initiating 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 TQta1s: 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 Ballasts Data Wiring: Heaters Signs 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: MICHAEL S SOBY Licensee: MICHAEL S SOBY Signature LIC.NO.: 10097 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:66 Lake Dr, Orleans MA 02653 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: $75.00 Aats L tve,r_fid) To Aire& eft�2t t CO1C-c: 8,( q (2i i. RECEIVED __ of / L, Co wealth o/Ma-MachuJe yr Official Use Only ; � AUG 17 2021 w icc77 Permit No. Z-0�( epoetment o f,}ire.ervicee v LiKy6..1rX Occupancy and Fee Checked 'iLDi' A` �F� PREVENTION REGULATIONS Rev. 1107 "a.- ,�r'v ------ ----_-- (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: 03( 1. 7/a City or Town of: Arr 61/1,4To the Inspector of Wires: By this application the undersigns ves notice of his or er intention to perform the electrical work described below. Location(Street&Number) 113 (,J i (pi, ZA Owner or Tenant ?...en pj i-ce-r'-t-7 koeit Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes n No (Check Appropriate Box) Purpose of Building S j(^,1Q vui t Lip k`.iN.S Utility Authorization No. Existing Service Amps / Volts Overhead n Undgrd 11 No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: UikriC4( Li.t(t _ ^ A( C -r fruk r R GL Le t cn S-}--et(Ca-1 CJy1 l Completion of the following table may be waived by the Inspector of Wires. Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Tf Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- 1-7 No.of Emergency Lighting grnd. 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 Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Sectio. y 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 TelecommunicationsNofDevices or Equivalent No.of Devices Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electric'I Work: 4�l 000 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE O E E: 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 El (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Soby One Home Services LLC LIC.NO.: 10097B Licensee: Michael Soby Signature /"'i'/ p LIC.NO.: 10097B (If applicable.enter "exempt"in the license number line.) Bus.Tel.No.:833-762-9663 Address: 9 New Venture Dr.Unit 4,South Dennis,MA 02660 Mt.Tel.No.: 774-216-0935 *Per M.G.L. c. 147,s.57-61.security work requires Department of Public Safety"S"License: Lie.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 'Downer's agent. Owner/Agent PERMIT FEE: S Ts Signature Telephone No. The Commonwealth of Massachusetts iC triDepartment of Industrial Accidents Office of Investigations 600 Washington Street ='+ Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Soby One Home Services LLC Address: 9 New Venture Dr.Unit 4 City/State/Zip: South Dennis,MA 02660 • Phone #: 774-216-0935 Are you an employer?Check the appropriate box: Type of project(required): 1.La I am a employer with 4. 0 I am a general contractor and 1 employees(full and/or part-time).* have hired the sub contractors 6. ❑New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling ship and have no employees These sub-contractors have g_ 0 Demolition working for me in ahy capacity. employees and have workers' [No workers' comp.insurance comp. insurance. 9. Building addition required.] 5. 0 We are a corporation and its 10 r lectrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 PIumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152,§I(4),and we have no employees.[No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number, I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:AIM Mutual Policy#or Self:ins.Lic.#: WCC50050242272021A Expiration Date: January 25.2022 , Job Site Address: ( � ( 1 c '(� V c - City/State/Zip: C rhr 4 402. 7p Attach a copy of the workers' compensation policy declaration page(showing the policy nu ber 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: p$/`1 '/ Phone#: 774-216-0935 -ff 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): ' I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: • Phone#: