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Home My WebLink AboutBLDE-22-005950 \`� Commonwealth of Official Use Only Massachusetts Permit No. BLDE-22-005950 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 EASE PRINT IN INK OR TYPE ALL INFORMATION) Date:4/18/2022 To the Inspector of Wires: City, or Town of: YARMOUTH his application the undersigned gives notice of his or her intention to perform the electrical work described below. :ation(Street&Number) 38 MONROE LN Telephone No. 'ner or Tenant Mark Tivnan 'ner's Address 38 MONROE LN,WEST YARMOUTH, MA 02673 his permit in conjunction with a building permit? Yes 0 No 0 (Check Appropriate Box) rpose of Building Utility Authorization No. Volts Overhead 0 Undgrd 0 No.of Meters fisting Service Amps w Service Amps Volts Overhead 0 Undgrd 0 No.of Meters ember of Feeders and Ampacity cation and Nature of Proposed Electrical Work: Replacement Furnace Completion of the following table may be waived by the Inspector of Wires. No.of Total o.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA o.of Luminaire Outlets No.of Hot Tubs Generators KVA v ❑ No.of Emergency Lighting fo.of Luminaires Swimming Pool Abo grnd.e ❑ In-grnd. Battery Units fo.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Detection and lo.of Switches No.of Gas Burners 1 Initiating Devices Total No.of Alerting Devices Jo.of Ranges No.of Air Cond. Ton Heat Pump I Number I Tons KW No.of Self-Contained Jo.of Waste Disposers Totals: Detection/Alerting Devices Local 0 Municipal ❑ Other: Jo.of Dishwashers Space/Area Heating KW Connection Security Systems:* go.of Dryers Heating Appliances KW No.of Devices or Equivalent No.of No.of Ballasts Data Wiring: Ele Water KW Signs No.of Devices or Equivalent 'Heatteo rs Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Work ted 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. y issue unless the licensee INSURANCE COVERAGE:Unless waived by the owner,no permit oor the r it substantial al equance ivfalent The undersigned certifies that such coverage proof of liability insurance including"completed operation"coverage is in force,and has exhibited proof of same to the permit issuing office. 0 (Specify:) CHECK ONE:INSURANCE 0 BOND 0 I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Rich M Melvin LIC.NO.: 21829 Signature Bus.Tel.No.: Licensee: Rich M Melvin Alt.Tel.No.: (If applicable,enter"exempt"in thSlicense YARMOUTH MA 026641207 Address:8 REARDON CIR, law.But my *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: WAIVER:I am aware that the License does not have the oliability insurance ner 0 n coverages en normally required by OWNER'S INSURANCE 0 signature below,I hereby waive this requirement.I am the(check one) PENT FEE: $50.00 Owner/Agent Telephone No Signature 7/2 7 22 Commonwealth of Massachusetts Official Use Onl ri Department of Fire Services Permit No. f= °y Occupancy and Fee Checked h 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 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:4/13/2022 City or Town of: YARMOUTH(WEST) 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)38 MONROE AVE, W YARMOUTH, MA 02673 Owner or Tenant MARK TIVNAN Telephone No. (508)826-1518 Owner's Address 13 CHICOPEE ST,WORCESTOR, MA 01602 Is this permit in conjunction with a building permit? Yes ❑ No ❑✓ (Check Appropriate Box) Purpose of Building DWELLING Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: FURNACE REPLACEMENT BASEMENT FURNACE. Completion of the following table mgy be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.oTotal 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. ❑ Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners 1 o.of itetection d Initiating Devices No.of Ranges No.of Air Cond. Tonsl No.of Alerting Devices Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑Municipal El Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of WHeaters ater KW No.of No.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: 5135 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 ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this ap lication is true and complete. FIRM NAME: E.F. WINSLOW PLUMBING &HEATING CO., I LIC.NO.:3281C Licensee: RICHARD MELVIN Signature LIC.NO.:21829A (Ifapplicable,enter "exempt"in the license number line.) Bus.Tel.No.:508-384-7778 Address: 8 REARDON CIRCLE SOUTH YARMOUTH,MA 02664 Alt.Tel. *Security System Contractor License required for this work;if applicable,enter the license number here: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)downer [7 owner's agent. Owner/Agent Signature Telephone No. I PERMIT FEE: $ E.F. Winslow Inspection Department email : inspections@efwinslow.corn The Commonwealth of Massachusetts Department of Industrial Accidents _X al 1.,Ili_" — , Office of Investigations = + Lafayette City Center p Inam mom A, /.7 2 Avenue de Lafayette, Boston,MA 02111-1750 ,$`' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: E.F. WINSLOW PLUMBING & HEATING CO, INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone #:508-394-7778 Are you an employer? Check the appropriate box: Business Type(required): 1.0 I am a employer with 99 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. [' Office and/or Sales (incl. real estate, auto,etc.) employees working for me in any capacity. 8. DNon-profit [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.0 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. #1964A Expiration Date:01/01/2023 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under§ 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 ce ' ,,,,. e the ins and penalties of perjury that the information provided above is true and correct ,f.•, ...►- Date: 12/01/2021 Signature: y' Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1.0Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia