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Home My WebLink AboutBLDE-23-001257 Commonwealth of Official Use Only ilfttP4) Massachusetts Permit No. BLDE-23-001257 "`".. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.1/071 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:9/9/2022 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) 179 CENTER ST Owner or Tenant MIKE LETTERA Telephone No. Owner's Address 179 CENTER ST,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: Removal of kitchen(cooking)facilities in garage building. 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 Above ❑ In- ElNo.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 Initiatine Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alertine Devices No.of Dishwashers Space/Area Heating KW Local 0 Municipal ❑ Other: Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Ballasts Data Wiring: Heaters Siens 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 0 (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: William C Fligg Licensee: William C Fligg Signature LIC.NO.: 12584 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:55 FREEMAN RD,YARMOUTH PORT MA 026752304 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 my 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 W C1I9 RECEIVED fe 14 e.... ww. a4 o� 0 8 2022 dial Use Only I. •' `,, jc-�� tNo. 217/ l zs7 3ypa tment* �}iro -- G DEPARTMENT . By. cy and Fee Checked ..‘ '. BOARD OF FIRE PREVENTION REGULATIONS-'Ettev. iro7] (leave blank) v APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cod,(M C),527 CMR 12.00 (PLEASE PRINT IN INK OR KITE ALL INF RMATION) Date: `l /Z.Z. City or Town of: Q'�'WIG V� \A, To the Inspector of Wires: 4 By this application the undersigned gives noti of his or her intenticVo perform the electriold work descnIrd below. � L Location(Street&Number) in -�i\ ,,c -C �'W�C'1 �C ,k44 G2� ) Owner or Tenant Mts .Q,,( Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes e o ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 4C:EL.J Amps 110/ ,f&Volts Overhead❑ Undgrd No.of Meters 1 v New Service Amps / Volts Overhead 0 Undgrd❑ No.of Meters Number of Feeders and Ampacity \ n A. Location Nature of Proposed Electrical Work: c.c 1n.�,U 1ti v�.p_B Cv�-c\s t`'� E-Zr �C6mp[etion of the following..tabk my be waived by the Inspector of Wires. tZ.. No.of Recessed Luminaires No.of Cell. (Paddle)Fans No.of Total -Sasp. Transformers KVA 1 No.of Luminaire Outlets No.of Hot Tubs Generators KVA a Above In- No.of Emergency fighting k No.of Luminaires Swimming Pool and. ❑ grn& ❑ Battery Units .j No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches O.of Gas Burners 'No.InDet intlon and �- Initiating Devices otal 1 V! No.of Ranges No.of Air Cond. To No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tam KW__°D �Self-Contained rtiqkDevices No.of Dishwashers Space/Areo Heating KW Local 0 Con 0 Other Heating Appliances KW Security Systems:* No.of Dryers No.of Devices or Equivalent No.o{Wa(er KWNo.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent TelecounicationsNo.Hydromassage Bathtubs No.of Motors Total HP of ItgW�nt OTHER: Attach additional detail if desirecL or as required by the Inspector of Wires. Estimated Value f ectrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE RAGE: 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 cove.is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [ ND 0 OTHER 0 (Specify:) I certify,under the painsand,pen�s ottp.erjury,that the information on this application is true and compkte FIRM NAME•V` `c v�( -�1 LIC.NO.: I Z'`)—3 Licensee: ' Signature ki(' LIC.NO.: (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: 71 'i 4-1`-59 Address: Alt.TeL No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.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)0 owner ❑owner's agent. Owner/Agent `PERMIT FEE: Signature Telephone No. The Commonwealth of Massachusetts ._ '/ Department of Industrial Accidents 701= 1 Congress Street, Suite 100 _4J j w Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Analicant Information Please Print Legibly Name (Business/Organization/Individual): ,\\ AN` ( 1 4) v . c Address: 9 j F%2,(v,,, City/State/Zip: YoNftriAiN< U Phone#: Or ' 1 Are you an employer?Check the appropriate box: Type of project(required): 1.❑l a employer with employees(full and/or part-time).* 7. ❑New construction 2.Yam a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] ❑ 3.0I am a homeowner doingall work 9. ❑Demolition myself[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.; 6.❑We are a corporation and its officers have exercised their right of exemption14.❑Other gh pti per MGL c. 152,§I(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 information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors 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: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL a. 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 and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.Citylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: