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Home My WebLink AboutBLDE-23-000917 Commonwealth of Official Use Only Massachusetts Permit No. BLDE-23-000917 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:8/22/2022 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) 1070&1074 ROUTE 28 Owner or Tenant DAVENPORT DEWITT TR Telephone No. Owner's Address 20 NORTH MAIN ST, SOUTH YARMOUTH, MA 02664 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: Permit for self installed equipment at liquor store. (#1078) 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- ❑ 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. Total No.of Alerting Devices 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 ❑ 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 Signs 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 of perjury,that the information on this application is true and complete. FIRM NAME: Guy Lento Licensee: Guy Lento Signature LIC.NO.: 28951 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:35 OAKDALE RD, NORTH READING MA 018642338 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: $330.00 2/c1"71. Residential . *_— C..ornmantveaa of Iaddachude ION /. cc�� 7 Official Use Only - ± 2 epartment o/`.}ire serviced Permit No.__e ___________ ___7___ ' _- BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked APPLICATION FOR PERMIT TO PERFORM [Rev. 1/07] (leave blank -�----- _.___ All work to be performed in accordance with the Massachuse tsEOR,al ELECTRICAL WORK (PLEASE PRINT DV INK OR TYP ALL IN ORMATION) Date: -ode l�4527 C Z 12.00 City or Town of: \f/Jrz-m d 790 ��ZZ By this application the undersigned gives notice of his or her intention to perform thmetrical o k described below. Location(Street&Number) l�'1� -�p'.2? Sr Owner or Tenantii�b(t!7� e S G f ✓Dees Owner's Address Telephone No. 9 r Is this permit in conjunction with a building permit? Yes II ` -- No (Check Appropriate Box) Purpose of Building Existing Service Amps / hTify Aut�iorization No. Volts Overhead 0 Undgrd 0 No.of Meters New Service Amps / — Number of Feeders and Ampacity Volts Overhead 0Undgrd 0No.of Meters _ Location and Nature of Proposed Electrical Work: C.A7' (/ CA4 y2 / Corn.letion o the ollowin•table in, be waived b the Inspector o Wires. (Paddle) No.of Recessed Luminaires No.of Ceil:Sus . No.of p Fans Total No.of Luminaire Outlets N Transformers KVA No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Abodve 0 In- `o.o mergency ig, mg No.of Receptacle Outlets rnd. ❑ Bette Units No.of Oil Burners - No.of Switches FIRE ALARMS No.of Zones No.of Gas Burners No.of Detection and No.of Ranges No.of Air Cond. Total Initiator_Devices No.of Waste Disposers Heat Pump Tons No.of Alerting Devices P m Number Tons DNo.et of Self-Containe •Totals: ..............b.,........_.. __. No.of Dishwashers Detection/Aierbs. Devices Space/Area Heating KW Munici al No.of Dryers HeatingAppliances Local❑ Connection ❑ ��' PP —_. KW Security S stems: - No.of T ater y —- Heaters KW No.of of No.of Devices or E uivalent No.Hydh a assage Bathtubs Si u p s Bella to Data Wiring: No.of Motorseh-communication Devices or E uivalent OTHER: Total HP No.of Devices or E a uiva ent Estimated Value of Electrical Work: i 0 Q % Attach additional detail if desired or as re Work to Start 11 7g j (When required by munici al ell required by the Inspector of Wires. Inspections to be requested in accordance with MEC Rule 10,and upon completion. i INSURANCE COVERAGE: Unless waived by the owner,no e U u the licensee provides proof of liabilitypermit for the performance of electrical work may issue unless undersigned certifies that such coverage is in force,and has exhibited proof of same to the e insurance including"completed operation"coverage or its substantial equivalent. The CHECK ONE: I certify,under the INSURANCE ains p�I BOND ❑ OTHER 0 (Specify:) P rmrt issuing office. f erjury,that the in FIRM NAME; rmation n this application is hue and complete: Qa Licensee: LIC.NO.: Address:ble,enter " empt"in the license n Signature 3 - ��d�� a line. LIC.NO.: rg *Per M.G.L.c. 147,s.57-61,security work requires es De ariAma° �� Bus.Tel.No.. at� *per M. 'S INSURANCE W Department of Public Safety" " Alt.Tel.No.: §. requiredOWNS ' law. Bymysignature WAITER: I am aware that the Licensee does not havethe liabilitcense:y Lin.No. .--- OWNER'S l;iiature below,I hereby waive this requirement. I am the(check one insurance coverage normally SignatureEl owner El owner's a;,ent. Telephone No. PERMIT FEE:$ PLEASE FILL OUT THE BACK OF FORM •The Commonwealth of Massachusetts • _�',l1�►= 1. Department nflnclustrialAccirlents :mil=, 1 Congress Street, Suite 100 .'-°fAf_ Boston,MA 02114-2017 . • ,., tv Www.mass.gov/ilia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 6l/lt ),-'4119--d Address: .' ,,cc OI J>.eikt. POO •stb4 City/State/Zip: iNA I '"I 11/4 Phone#: q7a 82-6 -8iP • Arc you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. New construction ;Eric;a sole proprietor or partnership and have no employees working for me in 8. EI Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. El Demolition 10 0 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(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. tContractors 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: I D>8 a �C _ City/Stat/Z p: C. y,p/kodRY /*A• Attach a copy of the work ers--eompensation policy de—Iara1ton page.(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 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 and th pains andpenalties perjury that the information provided above is true and correct. Signature: Date: —/—Z02 Z_ Phone#: r 7 J' 824, 9Jt7 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. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector • 6. Other Contact Person: Phone#: