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Home My WebLink AboutBLDE-22-007360 Commonwealth of Official Use Only fill Massachusetts Permit No. BLDE-22-007360 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:6/22/2022 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) 3 PUMP HOUSE LN Owner or Tenant KOWALSKI EDWARD J JR Telephone No. Owner's Address PARENTEAU KATHRYN B, 3 PUMP HOUSE LANE,WEST 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 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: Bath&bedroom addition 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 $rnd. 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. Total No.of Alerting Devices 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 Ballasts Data Wiring: Heaters Siens No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Eauivalent 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: THOMAS P SULLIVAN Licensee: Thomas P Sullivan Signature LIC.NO.: 18182 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:71 WAQUOIT RD, COTUIT MA 026353517 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 Ccxy_61,1 61041?2, e6 rt A4141/' f/M RECEIVED JUN 21 2022:j ...) tk; BU T l-tii0gtIRO Ak. -- " km"YB Cont42-70—usouveaah 0/Iiiimaso4"644 Official Use 014 . g c *, Permit No.022-" 77 1/4 ' e'2"r9_ . 2spartateisi olgins- owices at Occupancy and Fee Checked 41/4 ..- BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (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: (i 7 2_ / I z r Z City or Town of: (1 (i rgicul* To tile Inspector of wires: , - By this application the undersigdfd gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Z1)U1,414,0 1Ck --<, a- Cq. ‘- Owner or Tenant k to,q (.5 11\ Telephone No. .- Owner's Address Is this permit in conjunction with a building permit' Yes Er No 0 (Check Appropriate Box) ----- Purpose of Building ICS(ei,e4At i;x2 Utility Authorization No. Existing Service Amps / Volts Overhead 0 Undgrd E) No.of Meters — New Service Amps / Volts Overhead 0 Undgrd 0 No.of Meters (.... .. i Number of Feeders and Ampecity .. --- ' Location and Nature of Proposed Electrical Work: fp v^t Int&Av.( 1-6 6t,k,ik, k" 'B--eci Kill d , An Completion of the followinttable mg be waived by the lnsector of Woes. No of Total 4., No.of Recessed Luminaires No.of CefL-Susp.(Paddle)Fans Transformers KVA Ze, C No.of Luminake Outlets No.of Hot Tubs Generators KVA Swimming Pool Above 1-1 In- r-i No.ot Emergency Liming No.of Luminaires Swumm'aug ern& 1--1 grnd. " Battery Units No.of Receptacle Outlets No.of 011 Burners FIRE ALARMS No.of Zones .1-. N o.of Detection and ''"' No.of Switches No.of Gas Burners Initiating Devices I IL/ No.of Ranges No.of Air Coed. Tirslins No.of Alerting Devices .., Heat Pump Number Tons 1CW 4No.of Self-Contained No.of Waste Disposers Totals: Detection/Alelirgpevices No.of Dishwashers Space/Area Heating KW Local 0 tioulin:Z.alikut 0 Other No.of Dryers Heating Appliances Kw SecurftY S./stews:* No.of Devices or Equivalent No.of Water ., No.of No.of Data Wiring: Heaters '''''' Signs Ballasts No.of Devices or Equivalent Total HP Teleconimunicadons No.Hydromassage Bathtubs No.of Motors No.of Dmoices or Emily t OTHER: Attach additional detail#''desired or as required by the Inspector of Wires. Estimated Value ofpectrical Work: cr,9-2e--- (When required by municipal policy.) Work to Start: 6726/Z-Z 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE aff BOND 0 OTHER 0 (Specify: /ter*,ander the pains and loinalties ofperjary,that the info o this applkption is me and complete , FIRM NAME:-----1-F4'ft/4445 S o //maxi. LIC.NO.: 171/g.---/ LIcensee7T ,9JtJ Signature LIC.NO.: Wapplicable,wily,-''exempt"in the cense number line. , Bus.Tel.No.. Address: "! / Le/ L.,?er e‘y / Alt.TeL No.: *Per M.G.L.c. 147,s.57-61,4ecurity work requires Deparnueit 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,thereby waive this requirement. I am the(check one)Downer O owner's agent Owner/Agent Signature Telephone No. PERMIT FEE:$ 7,c.DC The Commonwealth of Massachusetts ►P,"-vl ►/ Department of Industrial Accidents 1 Congress Street,Suite 100• ='„et= Boston,MA 02114-2017 *v;,4 wwx.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. 9. ❑Demolition ❑ ys [No workers'comp.insurance required.] 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 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 These sub-contractors have employees and have workers'comp.insurance.* 13.[]Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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. 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 etpiration 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 penoldc of perjury that the information provided above is true and correct Signature: Date: 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#: