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Home My WebLink AboutBLDE-22-004128 '� Commonwealth of Ni Official Use Only �=`�� Massachusetts Permit No. BLDE-22-004128 • BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked APPLICATION FOR PERMIT TO PERFO I/RM RI EL rr All work to be performed in accordance with the Massachusetts Electrical Code (MEC),ELECTRICAL WORK (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) 527 CMR 12.00 DTo the Inspector25/2022 By this application the undersigned gives notice of his or her intention to perform the electrical work described below. of Wires: City or Town of: YARMOUTH Location(Street&Number) 26 WREN WAY Owner or Tenant ALGER DALE TRS Owner's Address ALGER NANCY TRS,26 WREN WAY, SOUTH YARMOUTH, MA 02664Telephone No. Is this permit in conjunction with a building permit? Purpose of Building Yes 0 No 0 (Check Appropriate Box) Existing Service Amps Utility Authorization No. p 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: Miscellaneous work er attached. 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 ra fir •rs Total No.of Luminaire Outlets No.of Hot Tubs V. Generators KVA No.of Luminaires SwimmingPool Above In_ rnd. ❑ •rnd. El No.of Emergency Lighting No.of Receptacle Outlets 4 l atte its No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 1 No.of Gas Burners No.of Detection and No.of Ranges I Martivi e No.of Air Cond. Total To No.of Alerting Devices Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers 'tal : No.of Dishwashers De •c 'i n Al•rti • Devi e Space/Area Heating KW Local ❑ Municipal No.of Dryers C n• Co 0 Other: Heating Appliances KW No.of Water KW No.of ik' ' t • • i eatersNo.of Ballasts Data Wiring: inns No.Hydromassage Bathtubs ,I.0 Devi •s i r E i uival•tit No.of Motors Total HP Telecommunications Wiring: OTHER: N . i iev•c•so i i ale Estimated Value of Electrical Work: Attach additional detail if desire d or as required by the Inspector of Wires. Work to start: (When required by municipal policy.) INSURANCE COVERAGE:Unless waivedinspection by the owner,no permit for the performance to be requested in accordance hof electrical work may MEC Rule 10,and issue comples t proof of liability insurance including"completed operation"coverage or its substantial equivalent.The undersigned certifies that such is in force,and has exhibited proof of same to the permit issuing office. unless the licensee provides CHECK ONE:INSURANCE 0 BOND 0 coverage I Certify,under the pains and penalties o OTHER 0 (Specify:) FIRM NA fPerjuty,that the information on this application is true and complete. ME: MANUEL A ANDINO Licensee: Manuel A Andino (If applicable,enter"exempt"in the license number line.) Signature LIC.NO.: 52474 *Per M.G.L.c. 147,s.57-61,security q M. Tel.No.: Address: 16 YANKEE DR, BREWSTER MA 026311876 OWNER'S INSURANCEty work requires Department of Public Safety"S"License: Alt.Tel.No.:WAIVER:I am aware that the License does not have the liability insurance coverage normally signature below,I hereby waive this requirement.I am the(check one) 0 Owner/Agent required by law.But my Signature owner ❑ owner's agent. Telephone No. PERMIT FEE:$50.00 / /j3 `�2 L.. Maaachueeits Official Use On , : 2 of 4 gips sawicas Permit No. �lr��U f!'�('J • BOARD OF FIRE PREVENTION REGULATION [ and Rev. Fee Checked 1/077 -- -- (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: 1 ' 1/ '2'X 1 City or Town of: 'fa,t,,,t.-"#t. To the Inspector of Wires: ki o By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Z to W t.e N W es Owner or Tenant tl't ice ( r y Owner's Address Telephone No...(z�3) z2 3- tin s y 4 Is this permit in conjunction with a building permit? Yes o Purpose ofEl No Er (Check Appropriate Box) Building R e s i n e>,.c� Utility Authorization No. Existing Service 1 bd Amps Ito/2-t a Volts Overhead d Er Undgrd 0 No.of Meters 1 New Service Amps / Volts Overhead❑ Undgrd Number of Feeders and Ampacity 0 No.of Meters _ Location and Nature of Proposed Electrical Work: /, Nam,, w,teM mown w.•rtu� �vr 2 tr}Wur 5owle doe,It ►rtS t, circa:i-t ` „aclo w4 k Zt�coiA. t„ c¢11dur RA ht• 04 elects% 9 lM�cvwldlta rt✓t,.�.3fsrv,�,wr 9 c pa.,,tl. F,reese.,. s�ro..;•� cellar, Ia�,.blS.sn� I(9k}ti;� eu+tt ;.,grObti.64 kely a.. Completion cif/mid1. • table be waived ill No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of by the/»sVector of Wires. No.of Lumhrain Outlets No. Total No.of Hot Tubs Generators KVA 4 No.of Luminaires Z. Swimming Pool , ' d.e [J n ❑ o.o mergency :' ; g No.of Receptacle Outlets L at: Uaib 1 No.of Off Burners FIRE ALARMS No.of Zones No.of Switches 1 No.of Gas Burners o.o ►^r*^ n a , t`° , ,, ,1, Devices No.of Ranges No.of Air Conn o` No.of Alerting Devices No.of WasteTones es nip uu.._ r its • ,, 'o.o Totals: _ Detection/Ale n , .No.of Dishwashers Devices Space/Area Heating KW LOCal •ant No.of Dryers Hating Appliances ❑ Connection 0 Other yy � o.a KW No.of>�evices nivalent Heaters KW `o.o `o.o �� or Wiring: S,-4,s Ballasts No.of Devices or No.Hydromassage Bathtubs No.of Motors Tota1HP tBivalent-Y, ,� , . ,ram ,.,. �� OTHER: No.of Devices or nt Attach"national detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: Work to Start: (When required by municipal policy.) Inspections to be requested in accordance with MEC Rule 10,and upon.completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the the licensee provides proof of liability insurance including"completed operation"coveragermance of electrical work may issueent. unless undersigned certifies that such coverage is in force,and has exhibited proof of same to theee or its substantialssuin equivalent. The CHECK ONE: INSURANCE [f BOND �°Of to permit issuing office. I e�►fY,wider the pains and 0 OTHER 0 (Specify,;) FIRM NAME: • �penalties off ''that the infirmedon on lids application is trite and complete. F+le(...t✓it 1N,• • Licensee:��„u,¢\ .A,d, < LIC.NO.: S2 47 a(lf aesee: ,enterSignature (Il . Al r...9—, LIC.NO.: "exempt" t license numberr line.) l Address: P o e•a k $4e, Bess.TeL No.:C-n�) t 22 'Per M.G.L.c. 147,s.57-61, az631 security work requires Department of Public Safety"S"License: A TeL No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liabilityinsurance Lic.No. required by law. By my signature below,I hereby waive thisIIIoa coverage owner's .!l Owner/AgentY Signature requirement I am the(check one III ■ ::eat. Telephone No. PERMIT FEE:$ S 0 --• ~ The Commonwealth of Massachusetts ti Department of Industrial Accidents _y, i _,_�;l- ^ 1 Congress Street,Suite 100 =!`:,y�7,1= :- Boston, MA 02114-2017 ; rJ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Legibly Applicant Information Name(Business/Organization/Individual): A nct l'vk o EA o c-k�►c c Address: P o Sex yR'1 City/State/Zip: 15 r e t, s#er NVq crz 6 3 o Phone#: (-Z-1 1/4-0 —1 1-2 —1- 3 9 7 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. 0 New construction ?❑1 am a sole proprietor or partnership and have no employees working for me in 8. [j Remodeling any capacity [No workers'comp.insurance required.) 9. ❑Demolition 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 []Building addition • 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.[�Electricai repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contactor ractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.; 14.❑Other 6.9 We are a corporation and its offices have exercised their right of exemption per MGL c. 152,§1(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 informatim t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 3Contractors 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:[� number and expiration date). Attach a copy of the workers' compensation policy declaration page(showing the policy Failure to secure*overage 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 a d a fine of pforo$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigationsof the nce coverage verification. pains do hereby c�ify under the and penalties of perjury that the information provided above is true and correct Signature: p.-kv^ -^-A Date: ' — 1I - 2k Phone#: A- -Akp°"4- Official use only. Do not write in this area,to be completed by city or town offudaL City or Town: Permit/License# Issuing Authority(circle one): Inspector 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing peC 6.Other Contact Person: Phone#•