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Home My WebLink AboutBLDE-21-006748 Commonwealth of Official Use Only '�' Lil :\ Massachusetts Permit No. BLDE-21-006748 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.l/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:5/20/2021 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 described below. Location(Street&Number) 56 MIRIAH DR Owner or Tenant BARSCH BETTY L Telephone No. Owner's Address FISCINA ANTOINETTE R, 56 MIRIAH DRIVE,YARMOUTH PORT, MA 02675 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: Replacement furnace. 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 No.of Luminaires Swimming Pool grad e ❑ grnd. ❑ No.of BatterEUnirgency Lighting 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 Space/Area HeatinLocal ❑ Munici al No.of Dishwashers P g KW Connection 0 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 Siens 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. required bymunicipal policy.) Estimated Value of Electrical Work: (Whenq p p 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 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:8 REARDON CIRCLE, SOUTH YARMOUTH MA 02664 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 • • Commonwealth of Massachusetts Official Use Only ,:t�_ Permit No. eZ`—(P7 4 e _,_,�i_ Department of Fire Services Occupancy and Pee Checked ) '-i== BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] 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 INMK OR TYPE ALL INFORMATION) Date: 5) ) 9 /Z I City or Town of: IfitrWIN HA 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) 56 ,In1d I A,h 6, Y, �1 O fyndd- c'1/f 026 75. U�` Owner or Tenant (1-\-, '6k i s C 11 Telephone No.q t 51 7 V 9 Owner's Address J Stita Is this permit in conjunction with a building permit? Yes I I No 1Check Appropriate Box) Purpose of Building t),)"Q1'1(il Utility Authorization No. Existing Service Amps • J/ Volts Overhead I I Undgrd I—I No.of Meters New Service Amps / Volts Overhead U Undgrd I I No.of Meters Number of Feeders and Amps city Location and Nature of Proposed Electrical Work: ry fyl K c . 105 f-ct RI 1-t`O7I Completion of the following table may be waived by the Inspector of Wires, tal No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers No.of Luminaire Outlets No.of Rot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- No.of Emergency Lighting grad. U grnd. I I 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. Total No.of AlertingDevices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWLocal! I municipal I I Other Connection No.of Dryers Heating Appliances KW Security'Spstexns:* No.of Devices or Equivalent No.of Water I 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; 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 ifs 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 application is true and complete. C (`�' FIRM NAME; E.F. WINSLOW PLUMBING &HEATING CO., III .LIC,NO.:3281 C ',rO t—S Licensee; RICHARD MELVIN Signature� 7 --- • LIC.NO.:21829A \15 (If applicable, enter "exempt"in the license number line) Bps.Tel.No.:5o8-394"7778 �, f} Address; 8 REARDON CIRCLE SOUTH YARMOUTH,MA 026e4 Alt,Tel.No,; *Security System Contractor License required for this work; if applicable,enter the license number here: 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) , owner owner's agent, Owner/Agent PERMIT FEE: $ 1Signatuigaature Telephone No, E.F. Winslow Inspection Department email : inspections@efwinslow.com The Commonwealth of Massachusetts , �� Department of In dustrialAccidents i Office of Investigations -•= Lafayette City Center -_:aost r 2 Avenue de Lafayette, Boston,MA 02111-1750 ,,a 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.[if I am a employer with 90 employees (full and/ 5• El Retail or part-time).* 2.1 I I am a sole proprietor or partnership and have no 6. ❑Restaurant/Bar/Eating Establishment employees working for me in any capacity. ❑ Office and/or Sales (incl.real estate, auto,etc.) 8. ❑Non profit 9. n Entertainment 10.0 Manufacturing 11•❑Health Care [No workers' comp. insurance required] 3.I I We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers' comp. insurance required]** 7 4•I I 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 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. Lie.#1964AExpiration 01/01/2022 Attach a copy of the workers' compensation policy declaration page(showing the policy Date: 01/01/2022 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 cer . •the ins and penalties o p f perjury that the information provided above is true and correct. Si afore: I° ^-, �� 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): lijBoard of Health 2.0 Building Department 3. EI all Selectmen's Office 6.[]Other all n Clerk 4.[ Licensing Board Contact Person. Phone#: www.inass.gov/dia