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Home My WebLink AboutBLDE-21-005179 Commonwealth of Official Use Only Et—RAM Massachusetts Permit No. BLDE-21-005179 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:3/12/2021 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice o1 his or her intention to perform the electrical work described below. Location(Street&Number) 21 MERGANSER LN Owner or Tenant BENOIT ROBERT T Telephone No. Owner's Address BENOIT JANE P, 21 MERGANSER LN,WEST YARMOUTH, MA 02673 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check ri 1 a) Purpose of Building Utility Authorization No. ar Existing Service Amps Volts Overhead 0 Undgrd 0 o e l New Service Amps Volts Overhead 0 Undgrd 0 on Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Remodel basement. 0 O Completion of the following table may be waive r of P Wires. No.of Recessed Luminaires 10 No.of Ceil:Susp'( )Paddle Fans No.of 1 Transformers �i No.of Luminaire Outlets No.of Hot Tubs Generators 1A No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets 13 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 6 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tons 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 0 Municipal Connection 0 Other: 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.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: y g 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: David M Hawkins Licensee: David M Hawkins Signature LIC.NO.: 31112 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address: 14 UNCLE JIMMYS LN,YARMOUTH PORT MA 026752252 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: $75.00 "").s . €( 5 i<(e zt f allf•-—• JCS, Commonweal 01 Mamacluaa.tts Official Use Only 2 Pemtxo z - sl`79 opariamat ti.S 440 . cy and Fee checked BOARD OF FIRE PREVENTION REGULATIONS [RevOcc-1JQ71 (leave blank)dti APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),47 ailt.12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: `3/ i/ / 1 City or Town of: i/)p lye : "1 To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work describeti below. Location(Street der Number) ', I 4��A (2,A-li)5 C -- ;,.,, VA-INN+l U� Owner or Tenant �.r)(& � f�r` A Telephone No. dQ Bl�f 0 3 6-3 - t Owner's Address S v".. 1 Is this permit in conjunction with a building permit? Yes J No 0 (Check Appropriate Box) Purpose of Building F l,l p,i ii- 6 PF z-M r A,) Utility Authorization No. Existing Service 'C9 Amps /dO/a ) Volts Overhead 0 Undgrd ref No.of Meters New Service Amps I Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity 1 I a 7o Location and Nature of Proposed Electrical Work: R r,, )3 . �-c,`- Completion of the fotlawin tale nt_97 be waived by the Inspector of Wires. No.of Total is No.of Recessed Luminaires () No.of Cel.-Sam.(Paddle)Fay Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 3 Swimming Pool grad.Abwve ❑ Igrad. 0 Battery Unit Lighting No.of Emergency 41 No.of Receptacle Outlets 1. 3 No.of OR Burners FIRE ALARMS No.of Zones .-> No.of Detection No.of Switches b No.of Gas Burners Devices I 1 x' No.of Ranges No.of Air Cond. ` Toms No.of Alerting Devices 'Heat Pump No.of Waste Disposers Number Tens, ,KW-.„ eted4o.of oS niAler Brkpeakes No.of Dishwashers Space/Area Heating KW Local 0 to token slider No.of Dryers Heating Appliances KW ;Sea of or Equivalent Na.of Water , No.of No.of Wiring: or t Heaters Signs No.of No.Aydromauoge Bathtubs No.of Motors Total HP Telecommunications No.of Devices or Enstividoist OTHER: Attach additional detail Vdesire4 or as required by the Inspector of Wires. Estimated Value of Electrical Work: 0_S CXJ (When required by municipal policy.) Work to Start: 3//� 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 cov is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND D OTHER 0 (Specify:) I coy,wider the pains and penalties of perjury,that the hifor on this awlication is true and complete FIRM NAME: LIC.NO.: Licensee: l F}v I b f t-A1-I..J k iiiic Signature LIC.NO.: L 3)))`), , — Of applicable.enter"exempt"in the license n lose.) Bus.Tel.No,: ti a a D 6 a Address: PI rvo l p ' b.n y x Lf' NA/2►va `f'4 P.9/Zi Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requuth 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 0 owner's agent. Owner/Agent Telephone No. I PERMIT FEE:a Signature The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 =' L= Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTINC AUTHORITY. ADDlicant Information Please Print Legibly Name(Business/Organization/Individual): 0/1) M_,, N Address: / LL j , e/l �In rn J i Iv City/State/Zip:\ rybc l-i-fbrO 1Mi , `,`fib' Phone#: `7'7 L/ - a 1 of U 9_ Are you an employer?Check the appropriate box: Type o project(required): LEI I a employer with employees(full and/or part-time).* 7. Q New construction 2.7 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. El Remodeling 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. !J Demolition 412 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insu rance.t 13. Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other I52,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also f511 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. lithe 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 pen of perjury that the information provided above is true and correct Signature: eA.LJ"te A A-- 3)/ l / o� Date: /� 1 Phone#: '/ 7y -D\/ Oh 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#: