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HomeMy WebLinkAboutBLDE-23-001666 Commonwealth of Official Use Only Massachusetts Permit No. BLDE-23-001666 Erg t 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:9/28/2022 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 describedd below. n cc Location(Street&Number) 174 WINSLOW GRAY RD A �j Z.\ "'O l-e Telephone No. Owner or Tenant Owner's Address GE�' ' oagoli 144 i (`per Is this permit in conjunction with a building permit? Yes 0 No 0 Cheer c1 Utility Authorizatio Now ' l `"�` Purpose of Building `� �`> •rs Existing Service 100 Amps Volts Overhead 0 Undgrd h ''":' New Service 100 Amps Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Replacement service Completion of the following table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- ❑ No.of Emergency Lighting No.of Luminaires Swimming Pool grnd. ❑ grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Air Cond. Total No.of Alerting Devices No.of Ranges Ton Heat Pump I Number I Tons 1 KW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices Local 0 Municipal ❑ Other: No.of Dishwashers Space/Area Heating KW Connection Security Systems:* No.of Dryers Heating Appliances KW No.of Devices or Equivalent No.of Water KW No.of No.of Ballasts Data of WDevices or Equivalent Heaters Signs Total HP Telecommunications Wiring: No.of Motors No.Hydromassage Bathtubs 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: Marcelo R Soares Signature LIC.NO.: 13036 Licensee: Marcelo R Soares Bus.Tel.No.: (If applicable,enter"exempt"in the license number line) Alt.Tel.No.: Address:53 FALMOUTH SANDWICH RD, MASHPEE MA 026494307 *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 oliia i lity❑ owner'insurance cs coverage normally required by law.But my r signature below,I hereby waive this requirement.I am the(check one) Owner/Agent Telephone No. PERMIT FEE: $50.00 Signature [ p 7� tki �6 6. , t(o,4_,44 clAt) camty2d i 6Pe n/ . Commonwealth of Massachusetts Official Use Only nl �I�.,% ��_ --« .i Permit No. 4-=1.72 `��t✓lcP Department of Fire Services y Occupancy and Fee Checked -, �4U...e BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/051 (leave blank) • APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 ClyiR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Oo(, 14:0 I a)- City or Town of: \IPS` < To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. ation(Street&Number) i�4 t r t. OvJ t/Owner or Truant p'A"1� `('C i cO CA 4 R.V'P 4.ki l/�elepltane Na.��(J j) I "� << ,3 Owner's Address 1 -i 11j I5 L O UU �R A-Y Is this permit in conjunction with a building permit? Yes © No (Check Appropriate Box) .J Utility Authorization No. I OP)'e J — Purpose of Building ' Existing Service Amps / Volts Overhead Q Undgrd 0 No.of Meters New Service Amps / Volts Overhead 0 Undgrd l_.s No.of Meters Number of Feeders and Ampacity �� Location and Nature of Proposed Electrical Work: C CO A. CXk1L tbtr) c-44,4 Cr 1)1 Ater) Completion of the fallowingrahle may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires Na.of Cell.-Susp.(Paddle)Fans Transformers KVA CGenerators V KVA #- No.of Lunninaire Outlets No.of Hot Tubs cJ Above' In- no.of Emergency lighting No.of Luminaires SwimM+ing Pool wad. © grnd. ❑ ..Battery Units *� No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones �J No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Air Cond. TO No.of Alerting Devices No.of Ranges tal Tons Heat Pump I Number•i Tans,,....LKR'....,, . No.of Self-Contained No.of Waste Disposers Totals: I' DetectiontAlerting Devices - Municipai Other No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ HeatingAppliances KW Security Systems:* No.of Dryers No.of Devices or Equivalent No.of Water No.of No.of Data Wiring:, Heaters KW Signs Ballasts No.of Devices or Equivalent Equivalent.. Wiring: No.Hydromassage Bathtubs No.of Motors Total AP • 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 providesproof 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 0 o i'lihR 0 (Slecifr) allies of perjury,that the information on this application is true and complete. I certify,under the pains and p Lie.NO.: t•7��7 � FIRM NAME: MC 45Ork Signature LIC.NO.: 'Z yi `1 Licensee: tu►A(l.t:�'1-� Bug.TeL No.: applicable,enter"exempt"in the license number line) Alt.Tel.No. Address: enter the license number here: *'Security System Contractor License required for this work;if applicable, coverage normally OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance0 owner's a nt required by law. By my signature below,I hereby waive this requirement. I am the(check one owner Owner/Agent" Telephone No. PERMIT FEE: $ 5 t)— Signature t C EMAIL ADDRESS'. M R • The Commonwealth of Massachusetts } ; rtt Department of Industrial Accidents �iir�_" 1 Congress Street,Suite 100 =° Boston,MA 02114-2 01 7 4Le wwwmass.govldia Workers'Compensation Insurance Affidavit:Builders/Contractors/Ele.ctricians/Piumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A t.licant ormationio Please ' r t 1 Name(Busine ss/Organ` - �i Address: • City/State/Zip: Phone#: Are you an employer?Check the appropria • .o=: +e of project(required) 1.0 I am a employer with employees u and/or part-time).* Q New construction 2.0 I am a sole propiletoror pailnership and have.,employees working forme in any capacity.[No workers'comp.insurance ] 8. Remodeling 30I am a hoc mp.tosruancc required.) wner doing all work myself.[No coo 'co t 9 Demolition 4.D r am a homeowner and will be hiring contractors to•.... all work on my property. I will i0 Building addition ensure that all contractors either have workers' on insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5E1 1 am a general contractor and I have hired the sub-co. . listed on the attached,. These sub contractors have employees and have workers insurancet 13.C:IRoof repairs • 6.0 We area corporation and its officers have exeicised their ._ of exemption per .s c. 14.El Other 152,§I(4),and we haven employees.[No workers'comp.•. required., *Any applicant that checks basil'most also fill out the section below .:wing their ,i :-:'compensation policy infoarmtinn. t Homeowners who submit this affidavit indicating they are doing all and �•'.>.outside contractors must submit a new affidavit indicating such. tContracxars that check this box must attached an additional sheet showing of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their comp.policy number. I am an employer that is providing workers'compensation.I • =nee for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: - Job Site Address: City/State/Zip: Attach a copy of the workers'compensation p+ cy declaration pag• (showing the policy number and expiration date). Failure to secure coverage as required under =L c. 152,§25A is a c violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civ' penalties in the form of a •P WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this sta rr ent may be forwarded to the r,i ce of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains an penalties ofperjury that the in_for ,+. r nprovided above is true and correct Sias.' e: Prose Official use only. Do not e in this area,to be completed by city or town o • L City or Town: Permit/License# Issuing Authority( cle one): I.Board of Health 2,Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector S.Other Contact Person: Phone#: •