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Home My WebLink AboutBLDE-23-000646 Commonwealth of Official Use Only A Massachusetts Permit No. BLDE-23-000646 _ 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:8/8/2022 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) 58 WEIR RD Owner or Tenant KERRY BARTON Telephone No. Owner's Address 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: Miscellaneous work per attached. Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires 4 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 A bovend. ❑ grnd ❑ No.of Emergency Lighting r Battery Units No.of Receptacle Outlets 2 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 9 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Ton No.of Waste Disposers Heat Pump Number Tons 1 KW No.of Self-Contained 8 Totals: Detection/Alertine Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other: Connection No.of Dryers Heating Appliances KW Security Systems:* No No.of Devices or Equivalent HeatersWater KW No.of No.of Ballasts Data Wiring: Siens 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 S eci I certify,under the pains andpenalties o (Specify:) fperjury,that the information on this application is true and complete. FIRM NAME: MICHAEL J LEBLANC Licensee: Michael J Leblanc Signature LIC(If applicable,enter"exempt"in the license number line.) Tel. NO.: 17423 Address: 16 Westwind Cir, Osterville MA 026551375 Bus.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt.Tel.No.: 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 ;26,u‘ii (5-190/ry re 6)10 i r...44..s 14 s iv>) m i-cam ci'// 2 e{ `I' i., RECEIVED AUG 0 8 �0 ol//lagleachueetta Official Use Only B #' spriiinsni /gire S' Permit No. ti-- °BUILDING DEPARTMENT % t �� sY: Occupancy and Fee Checked ', ,, -R^-rtr'- }Rr-EREVENTION REGULATIONS [Rev. I/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 T17E/ALL INFORMATION) Date: i.k )j-� g , City or Town of: q Ct� To the Inspector of Wires: 3 el By this application the undersigned gives notice f his or her intention t onn the electrical work described below. Location(Street&Number) i` �� ri►SJ��td� `�" liOwner or Tenant lecc r\ ' Telephone No. AI Owner's Address 4,t 1%? gpb> Aj ��, V Is this permit in conjun with a building permit? Yes la No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. 6 Existing Service )a( Amps J 20 /a►ji)Volts Overhead Undgrd g 0 No.of Meters ___[_ 41 New Service Amps / Volts Overhead 0 Undgrd ElNo.of Meters a Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: tiSIve \. I Si-al 02 Iott_ �41 S �Rqc Sake 5Nr iet�. bba,�e tkvai & zt3 r-kar, 5�cI eS T1� Completion of thefollowinntable may be waived by the! tor of Wires. No.of Recessed Luminaires �l Na.of Cdl.-Soap.(Paddle)Fans No.of I �` Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires ,2 Swimming Pool Above ❑ In- ❑ Pio.if Emergency Lighting rnd. grad. Battery Units No.of Receptacle Outlets Z No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 1 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices No.of Waste Disposers Heat Pump Number„ Tons rKW No.of Self-Contained Totals: . Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local Municipal ❑ Connection 0 Other No.of Dryers Heating Appliances KW sty Systems:* Na.of Water ' No.of Devices or Equivalent No.of No.of Heaters Signs Ballasts Data Wiring: 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 desires[or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:C313'J0 jiti2g2..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 coviirage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 141 BOND 0 OTHER 0 (Specify:) I certify,under the its and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: 1`73 Licensee: Ile t ) w g,L.iLs LIC.NO.: (/fapplica ent "exempt"i�he ice tuber ti Signature LIC.NO._� } Address: .�. ' Bus.Tel.No.Ma �i/l — *Per M.G L c 147,s 57 6I,security work Alt.Tel.No.: h' requires 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 a:ent. Owner/Agent Signature Telephone No. p PERMIT FEE:$ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 is.= Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. z TO BE FILED WITH THE PERMITTING AUTHORITY. A• 'lica Information Please Print Le.'IA Name (Business/0 =: ization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the app priate box: T :e of project(required): 1.0 I am a employer with em• .gees(full and/or part-time).* . 0 New construction 2.0 I am a sole proprietor or partnership an. have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insu . e required.] 9. El Demolition 3.0 I am a homeowner doing all work myself. workers'comp.insurance required.]t 10 ❑Building addition • 4.❑I am a homeowner and will be hiring contracto to conduct all work on my property. I will ensure that all contractors either have workers'c..pensation 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-con., •rs listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have worke comp.insurance.* 6.0 We are a corporation and its officers have exercised their ri •t of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.i urance required.] *Any applicant that checks box#1 must also fill out the section below sh. ,'ng their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work• then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet show g th- e of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provid eir wo - 'comp.policy number. I am an employer that is providing workers'compe ation incur, ce for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: .ity/State/Zip: Attach a copy of the workers' corn g•nsation policy declaration page(showin i e policy number and expiration date). Failure to secure coverage as requ' ed under MGL c. 152,§25A is a criminal violati• punishable by a fine up to$1,500.00 and/or one-year imprisonment, _- well as civil penalties in the form of a STOP WO' \ORDER and a fine of up to$250.00 a day against the violator.A co• of this statement may be forwarded to the Office of Inv- tigations of the DIA for insurance coverage verification. I do hereby certify and• the pains and penalties of perjury that the information provide, • •ove is true and correct Si•nature: Date: Phone#: Official us= only. Do not write in this area, to be completed by city or town official • City or own: Permit/License# Issui g Authority(circle one): 1. :oard of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbic Inspector 6. •then Phone#: Contact Person: