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Home My WebLink AboutBLDE-23-001954 i �D , Commonwealth of Official Use Only f : lilk,,.� Massachusetts Permit No. BLDE-23-001954 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:10/13/2022 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) 66 WEST GREAT WESTERN R (/r( Owner or Tenant Starbuck Construction Telephone No. i Owner's Address 17 Sudbury Lane,Hyannis,Ma 02601 `G1� Is this permit in conjunction with a building permit? Yes 0 No ❑ (Ghee![...; Purpose of Building Utility Authorization No Existing Service Amps ' P Volts Overhead 0 Undgrd ❑ .: , New Service Amps Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Temporary Service 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 gr hoveod. nd❑ gr ❑ No.of Emergency Lighting Battery Units a 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 Tons 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 0 Municipal 0 Other: Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of Devices or Equivalent Heaters KW No.of No.of Ballasts Data Wiring: Sins 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: EAV SOLUTIONS Licensee: JEFFREY S DEROUEN Signature LIC.NO.: 22206 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:110 Hedges Pond Road,Plymouth MA Alt.Tel.No.: *Per M.C.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 nonnally 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. I PERMIT FEE:$50.00 I \ � t01i� Izv ( L 4, • , RECEIVED Print Form *_ ��ormanursalth 0////a�acleudsffe fficial Use Only , � Ct OCT 112022��o`.7uPe Serves Permit No. • „a i�u tt lWr\K E PREVENTION REGULATIONS Occupancy and Fee Checked Y-- - [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: 10/11/22 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)66 West Great Western Road Owner or Tenant Starbuck Construction Services Telephone No. 508 827-7134 Owner's Address 176 Sudbury Lane Hyannis Is this permit in conjunction with a building permit? Yes Q No ❑ (Check Appropriate Box) Purpose of Building House Utility Authorization No. 10604066 Existing Service Amps / Volts Overhead n Undgrd g ❑ No.of Meters New Service 100 Amps 120 / 240 Volts Overhead n Undgrd g n No.of Meters 1 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Temporary service 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 INo.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump I Number!Tons I KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of Devices or Equivalent Heaters KWNo.of Data Wiring: Signs Ballasts 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: 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 [ BOND ❑ OTHER I certify,under the pains and penalties o � (Specify:) f perjury,that the information on this application is true and complete. FIRM NAME: EAV Solutions, LLC Licensee: Jeffrey Derouen LIC.NO.:860 Al Signature p.,g LIC.NO.:22206-A (If applicable,enter "exempt"in the license number line.) Address: 110 Hedges Pond Road Cedarville, MA 02360 Bus.Tel.No.:(508)245-7155 Te*Per M.G.L. c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt.Lic'.No. (781)589-5692 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 El owner ❑owner's a.ent. Owner/Agent Signature Telephone No. PERMIT FEE: $50.00 The Commonwealth of Massachusetts Department of Industrial Accidents o - Office of Investigations 1I11= 5600 Washington Street Boston,MA 02111 �� „,. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): I EAV Solutions,LLC- - -- --" Address: 110 Hedges Pond Road I City/State/Zip: Cedarville,MA 02360 1 Phone#: 508 245-7155 I Are you an employer?Check the appropriate box: Type of project(required): 1. eil I am a employer with 8 4. inI am a general contractor and I 6. El New construction employees and/or part-time).* have hired the sub-contractors (fullp ) 7. Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet.t ship and have no employees These sub-contractors have 8. In Demolition working for me in any capacity. workers' comp.insurance. 9. 0 Building addition [No workers' comp.insurance 5. ID We are a corporation and its 10.(3 Electrical repairs or additions required.] officers have exercised their 3.0 I am a homeowner doing all work rightexemption of per MGL 11.D Plumbing repairs or additions p myself. [No workers' comp. c. 152,§1(4),and we have no 12. Roof repairs insurance required.]t employees. [No workers' 13.113 Other Temporary service 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. I Insurance Company Name: IThe Hartford 08WECAH 1 DJN 18/6/23 Policy#or Self-ins.Lic.#: Expiration Date: 166 West Great Western Road City/State/Zip: 'Yarmouth,MA 02675 1 Job Site Address: Attach a copy of the workers'compensation policy declaration page(showing the policy number 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 certify under the pains and penalties of perjury that the information provided above is true and correct 110/11/22 Signature: P4hbLl.4..rL Date: Phone#: 781 589 5692__ 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 Phone#: Contact Person: