HomeMy WebLinkAboutBLDE-21-002373 0 Commonwealth of Official Use Only
I'E.11% ; Massachusetts Permit No. BLDE-21-002373
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:10/29/2020
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) 69 ICE HOUSE RD
Owner or Tenant MURRAY MARY I Telephone No.
Owner's Address 16 LENOX PL, SCARSDALE, NY 10583-7211
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 ❑ 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: Replacement boiler.
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 ove ❑ In- ElNo.of Emergency Lighting
Abgrnd. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners 1 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/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local 0 Municipal 0 Other:
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters 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: 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 ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: RICH M MELVIN
Licensee: Rich M Melvin Signature LIC.NO.: 21829
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address:8 REARDON CIR,S YARMOUTH MA 026641207 Alt.Tel.No.:
*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
Signature Telephone No. PERMIT FEE:$50.00
t1 40174 }/CSle j el(VII
4\12,A-- `t( /u C (0::ioem
r
commonwealth of MaSsaChusetts
Ofiloial Use Qa
�� I f ; FIRE PREVENTION REGULATIONS�" f•F.ire Services Permit No. v2t - Z
Department o
BOARD OF
•
`,.,,,,,aOccupancy and Pee Checked
APPLICATION FOR PERMIT �e"'9/051 save blank i 1—"`"'
AllWorktobepartbrmedln$ERMIT,TOaPERFORM ELECTRICAL
C1'LEASTiPR1NTxNrNKORrfbj edSINFO WORK
INFORMATION ®�Z'527ta.00
City or Town of ) Date;
By this application the underalgnee l '
Location gives of oe o s or er intent on to performt the g�for o(Street&Number) 6i GL 1 e �� ttelectrical work desorlbed below.
Owner or Tenant ,y\ Wl d v 41.
Owner's Address
Is this permit in conJu co vv on A� b •
$i Telephone No, d 5 g 7
a building permit? YesExisting Service ❑ No �(Check Appropriate Box) •
Purpose of Building
Am a 'Utility Authorization No.
p --_. ,•,_Volts Overhead
rvf ❑ YJndgrd
Number of Feeder d Ampacity Volts ❑ No,of Meters -�--___
Amps "",�-- -- Overhead❑ 'Undgrd
Location and Nature of Proposed Electrisral Worit: ' 0 No.of Meters ��
ter
No.of Recessed Luminaires •c0 !`tloq' th
llowin fable be abed b !lie Ins actor
o
No.of Ce11.-8usp. �adle rcAhB
No.of Luminaire Outlets � o.b IV res.
No.of Not Tubs Transformers • KVA
No.of Luminaires • Generators
. Swimming Pool. ; eveI�—� n. IC'VA
No,of Receptacle Outlets d• I--•i rnd. ❑ o'° tr,r:ency g
No.of Oil Burners 1 L' "No.of Switches
No.of Gas Burners ALAS No,of Zones
No.of Ranges `0.0 gee `on an.
Nb.of Air Cond. • o a Iriitibtin Devices
No.of Waste Disposers
'oat' snp Tons No.of Alerting Devlcbs
No.of Dishwashers Totals: � ..ply,,,„,, " o.o e
on ne ,
Space/Area heating KW
Date on/A artful Devices
No.of DryersLocal[] un c pa
o.o a r heating Appliances I `sour Conneetlon• ❑Other
!Beaters KW o.o ` sternal i
si ne � o•of 'ev ces or E uivalent
No.Ilydromassage Bathtubs Ballasts
Data !rings ,
OT$�RO 1Vo.of Motors ' No.of evic or vasont
Tots)HP• e e :filit s:a ens, gg,�
•
No.of Devices or E ul va at
Estimated Value of Electrical Work:•
Ailed:additional detail deslrerl,or as re
Work to Start: (When required by municipal policy.)
Oohed by tbe•Inspeotor INSURANCE COVE XnspB°tions to be requ®sted.in accordance with wrWlres
the licensee provides proof of liability insurance including the o '�co no !Sled ,�
Uniess waived by the owner, permit for the performance of eh:atriaal work may h2EC Rule to,and upon opmpietlon,
`vn • undersigned!kegs ed certifies proof
f of coverage insurance
ra cethr n,and hasexhibited
p operation"cq CHECK ONE: INSURANCE exhi`ltpe proot'of same to pere ormit issuingtogfioouivalente unless
]'cert(/y,under the pains andpenalties O� 0 OT'HER ❑ S eoifys)
PllIttM NAME: E.F.WINSLOW PLUMBING
& that the Informationon this a newton is true and complete.
r--! Licensees RICFtARp MELVIN &•HI±ATINQ CO.,i. mplete: '
® �- (ddretoable,enter"excerpt"in the license+?umbtr7tns� Signature ------... •LIC.N'O.:3281 C
Address; a REARDON OIROLE SOUTH YARMOUTH,MA 02884
'" LTC.NO.:21829A
, --
OWNER'S e INSURANCE WAIVER:
License required for this work;!f applicable, Bus,Tel,No.�e gg y7";"'e
Oquired bylaw, I am aware that the Lioa age does not have the liability ranee No,,;
e� Owner/A nt By my signature below,I herebythe license number hare;
Signature waive this requirement. I am the(check one °°°° °age nose~--' r a 1y
Telephone No. owner • owner's a ant.
. •
The Commonwealth of Massachusetts •
Department of IntlustrialAmidents
_,�li= Office ofInvestigations
Lafayette City Center
2 Avenue de Lafayettea Boston,MA 02111-1750
•
www..mass.gov/dta
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: BusinessType(required):
1.El I am a employer with 80 employees (hill and/ 5. ❑Retail
or part-time).* _— -6. 0 Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no
7. ❑Office and/or Sales kind.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 10.0 Manufacturing •
no employees. [No workers' comp.insurance required]** MO Care
4.❑ We are a non-profit organization, staffed by volunteers,
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 bqx#1.
1 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.Lie.#1909A Expiration Date;01/01/2021
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 anc/or one-year imprisonment, as well as civil penalties in the.£orm 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 insulimce coverage'verification,
1 do hereby cer ' the •ins and penalties of perjury that the information provided above is true and correct.
31gnatur7e e'* l l�--� Date�01/02/2020
'�
Phone#; 508-394-7778
Official use o'aly. Do not write in this area,to be completed by city or toxn officdaa
City or Town: Permit/License#
Issuing Authority(check one):
1 f Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.0LicensIng Board
50 Selectmen's Office 6.[]Other -
Contact Person: . Phone#:
www.mass.gov/dia
, i