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Home My WebLink AboutBLDE-21-005262 A/1)2 Commonwealth of Official Use Only e St j. ' Massachusetts Permit No. BLDE-21-005262 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:3/15/2021 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pertorm the electrical work descrriibed M ''' obelow. Location(Street&Number) 4 BEVERLY RD 3 ieS Owner or Tenant REJNIAK MARK A Telephone No. Owner's Address REJNIAK BARBARA E, 16 GILBERT RD, SOUTHAMPTON, MA 01073 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 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: Install air conditioning. 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 TotalTransformers 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 No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. 1 Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices Space/Area HeatingKW Local ❑ Municipal No.of Dishwashers P Connection ❑ Other: HeatingAppliances KW Security Systems:* No.of Dryers PP No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent 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. Estimated Value of Electrical Work: (When required by municipal policy.) y' 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: E F WINSLOW PLUMBING HEATING CO INC LIC.NO.: 21829 Licensee: RICH M MELVIN Signature Bus.Tel.No.: (If applicable,enter"exempt"in the license number line.) Alt.Tel.No.: Address:8 REARDON CIRCLE, SOUTH YARMOUTH MA 02664 *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 liability insurance coverage normally required by law.But signature below,I hereby waive this requirement.I am the(check one) 0 owner 0 owner's agent. Owner/Agent (PERMIT FEE: $50.00 I Signature Telephone No. °7a' ct 7-(0/Zi -- ---. Commonwealth of Massachusetts Official Use Only - -a - 5Z( 2' _, Permit No, �I_ Department of Fire Services Occupancy e'. -�-f—,,, BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] and Fee Checked y'•,.� (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: 'j/)Z /Z City or Town of: 'wi j}-(,, 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) ? &A ft I I'i) lj 55 f YarnovUi o u -1 3 // Owner or Tenant 11(All< l\e�)inlaic TelephoneNo.SQ'5Z 779Tj 5 Owner's Address [ f u l l0ei]- Rd SOv fi& Act en,/-0 i Is this permit in conjunction with a building permit? Yes ❑ No heck Appropriate Box) Purpose of Building bv,J6A I VI-9 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: P F C S'l 11 u t•-r'Go Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Tf T 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. ElBattery Units 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 Total g No.of Air Cond. Tons 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 LocalEl Municipal ElOther Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water No,of No.of KW HeatersData Wiring: SignsBallasts 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. ,O CHECK ONE: INSURANCE ® BOND ❑ OTHER 0 (Specify:) I certify,under the pains and penalties of pedury,that the information on this ap lication is true and complete. FIRM NAME: E.F. WINSLOW PLUMBING& HEATING CO., I LIC.NO.:3281 C Licensee: RICHARD MELVIN Signature LIC.NO.:21829A 1' (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.:508-394-7778 Address: 8 REARDON CIRCLE SOUTH YARMOUTH,MA 02664 Alt.Tel.No.: N *Security System Contractor License required for this work; if applicable,enter the license number here: l `D 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. 1 am the(check one)downer n owner's agent, Owner/Agent _-_ Signature Telephone No. PERMIT FEE: $ ' E.F. Winslow Inspection Department email : inspections@efwinslow.com a._ _ The Commonwealth of Massachusetts w Department of Industrial Accidents Wil='� ..w'1 aaa. Office of Investigations Lafayette City Center ` 2Avenue de Lafayette,Boston,MA 02111-1750 ini 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-a-pprapriate-bax: Business Ty pe ): -- ---1.111 I am a employer with 90 employees (full and/ 5. ❑Retail or part-time).* 2.CII am a sole proprietor or partnership and have no 6. Restaurant/Bar/Eating Establishment 7 ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have no employees. ** 10.[]Manufacturing [No workers' comp. insurance required] 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp.insurance req.] 12.0 Other *Any 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 01/01/2022 Expiration Date:Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to securecoverage 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 cer � the ins andpenalties o / (perjury that the information provided above is true and correct. Signature: 7' -y ...pi:N. -- 01/02/2021 Date: 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 3.0 City/Town Clerk 4.['Licensing Board 5.11]Selectmen's Office 6.[]Other Contact Person: Phone#: www.mass.gov/dia