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Home My WebLink AboutBLDE-22-004126 Commonwealth of Official Use Only Massachusetts Permit No. BLDE-22-004126 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:1/25/2022 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) 142 LONG POND DR Owner or Tenant Adam Miller Telephone No. Owner's Address 142 LONG POND DR, SOUTH YARMOUTH, MA 02664-4144 Is this permit in conjunction with a building permit? Yes ❑ 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 ❑ Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Miscellaneous per attached. 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 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 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: MANUEL A ANDINO Licensee: Manuel A Andino Signature LIC.NO.: 52474 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address: 16 YANKEE DR, BREWSTER MA 026311876 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:$100.00 P--ty-er04(5511J6 i) (jz8(9- . s" 1.a Af4040004004gai 7 s'/laeeadiaeeits Official Use Only Permit No. l�22, '� lG(Z .c: ' a Zeparimant o`}ins.S r ced Occupancy and Fee Checked „ ,,.,r, SOAK)OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) 1 APPLICATION FOR 'RMIT TO PERFORM ELECTRICAL WORK t I A rc to be performed 4 accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 wa ? (PLEASE'PRINT IN INK OR TYPE AAL INFORMATION) Date: ( — 'L`i - ti Z- o City or Town of�, - -rmo LA-k f To the Inspector of Wires: By this application the undersigned giv **ice of his or her intention to perform the electrical work described below. - v LoVlloa4Streret&Nswlber) I y. 2- L o,•+ pa�cf D/‘rv-e Owner or Tenant _ A,919.444 _ M i 7(-e r Telephone No.(51 o)703-S( ,7 A` Owner Address _ ti # 1 Is this perm*Aadfoupiaction with a building penult? Yea ❑ No ❑ (Check Appropriate Box) Z Purpose of Building , R-e-s„iele.:.tc a Utility Authorization No. d S f I Existing Service a ea Amps` 1 /2-4 c' Volts Overhead la- Undgrd ElNo.of Meters 1 d1 New SegJee Amps / Volts Overhead El Undgrd El No.of Meters € Number of Feeders and Ampactty 1 Location and Nekton;K Proposed Metrical Work: .Po-,..4-.e,l IA.*yet e rzn-1,n ova,l-t el-. l N t 8 Act roevl /.l ail I k. NoJtl...Bart-IA , l-:vri icJ ro sir 2-. vJs d:'rtimy Z eut°e-��- 'NI S t I eac+orr'ov 1,pr,t1 tl S'iloke o 1- a I a,v-wi s t c,etl a r. s l'air3 p f +-l3oi ler S. Completion of thefollowingta5le my be waived by th r of Wires. 1.t No.of Recessed Luminaires No.of CeiL No.of Total ,, .(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators ezt,, No.of Luminaires Swimming.pool Above In- No.of Emergency Lighting gand. ❑ grnd. ❑ Battery Units 'z` No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones '` No.of Switches No.of Gas Burners No.of Detection and t. Initiating Devices l No.of Ranges No.of Air Cond. Tuna No.of Alerting Devices No.of Waste Disposers 'Heat Pump Number Tons KW No.of Self-Contained Totals: . ___ ._ .._.._...._.. Detection/Ale . Devices No.of Dishwashers Space/Area Heating KW Local Mun l ❑ Connection ❑ ' No.of Dryers Heating Appliances KW SecurityN Systems:* or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or luivalent No.Hydromassage Bathtlrba ' INo.of Motors Total HP Telecommunications No.of Devices or went 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: I- 2.0- zZ 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 w$etaigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHICK ONE: INSURANCE Z BOND 0 OTHER 0 (Specify:) I cm*,under the pains imd penalties of perjury,that the information on this application is awe and complete. FIRM NAME: Av wc(t.-vaa-.» - t.-14e.c.t r;� r 1 vt c. • LIC.NO.: 52-y7 y 6 Licensee: Ma.vUce1 A v‘At n.a Et2c4rkta-NA Signature kt. 4'4__dt;t4,o LIC.NO.: (If applicable,enter"exempt"in t*license n nrber line.f ° Q o Address: a'. r' Bus.TeL No.:C7 `I)7 ZZ-23q 7 at 381 13 r` s-F�- MA o263 I Alt.TeL No.: ''Par M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVWIt: i am aware that the Licensee does not have the liability insurance coverage normally to �Win=. By my signature below,I hereby waive this requirement. I am the(check one)0 owner 0 owner's agent. Signature Telephone No. I PERMIT FEE:$ /0 0 — _ 14 % , The Commonwealth of Massachusetts 61�1= t Department of Industrial Accidents f =:iiiil a 1 Congress Street, Suite 100 _t _'S�1 -IfBoston, MA 02114-2017 1 y'�^��. www mass gov/dia 1.. ' Workers'Compensation Insurance Affidavit: Builders/Con tors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING A ' HORITY. i ii. Applicant Information ' ' Plea Print b` bl Busmess/O ` .. Name � rgamzation/Individual): �:��,,�� ,�.�.��.�v.;.� Address: 190 lox 5 81 Jo ow-- City/State/Zip: PJ(-124.43.4-e N 1A 63► Phone#: (11 `i) 7-Z.2 2-.31 7 Are you an employer?Check the appropriate box: t� ,' Type of pinoje quirea): I.❑I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8- Remodeling. 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ,...... 9. ❑Demolition ,.: 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.[ $IeiCtrical repairs or additions 5. I am a general contractor and I have hired the sub-contractors12.Q Plumbing repairs or additions These sub-contractors have employees and have workers'com insu anc attached sheet 13.0 Roof repairs 6.dWe are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 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'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. Contractors 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: A lkv.. w(... I �. �-..a Date: — 2— 1— 2 2— ,# ; P one#: S YES. T ,, �-a Official use only. Do not write in this area,to be completed by city or town officiat 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 f ; P Contact Person: ' . Phone#: '"