Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
BLDE-23-001207
Atm Commonwealth of Official Use Only Massachusetts Permit No. BLDE-23-001207 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) D ate:9/6/2022 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her intention top the electrical work described below. Location(Street&Number) 17 THACHER Owner or Tenant JOAN BRAZEAU Telephone No. Owner's Address 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 ❑ No.of Meters New Service Amps Volts Overhead 0 Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install generator 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 1 KVA 14 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. To 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 ❑ 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 ❑ 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: Roger J Nascimento Licensee: Roger J Nascimento Signature LIC.NO.: 17024 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:29 SHARON ANN LN, E FALMOUTH MA 025366034 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 (c° (cY. l/J 2z- . . _ RECEIVED _. 14 SEP 0 2 20210 �.a&e/rnaaeac�edreelfe Official Use Only to 0 _ ? Permit No. .-2S - (2 7 !sTILDING DEPART ups IJwicde3 " =• ' ' a • - PREVENTION REGULATIONS1/41/4 cy and Fee Checked ° (1rave 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 INFO O Date: fir'— /_ �z..2, ® City or Town of: rd�%/L o'f7/7 To the Inspector of Wires: ki By this application the undersigned gives notice of his her intention,perfony the electrical work described below. • Location(Street&Number,01 ' ,T Owner or Tenant ).04'47 74 2 rq Telephone No. .' i Owner's Address /i� TZ a c AC-- .�to Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) - Purpose of Building Utility Authorization . v ExistingServce ' e c7 � Amps ),�fl! 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: le., ye ill g-€4 r.,"e 7-0r- Completion of the following table may be waived by the Inspector of Wires. 4 No.of Recessed Luminaires No.of Celt-Snip.(Paddle)Fans "fro.of obi Transformers KVA c:,, No.of Luminaire Outlets No.of Hot Tubs Generators cy KVA rq r No.of Luminaires Swimming pool Above In- Pio.of Emerge Lighting g grad. grad. Battery Units 1z No.of Receptacle Outlets No.of Oil Burners •~ FIRE ALARMS No.of Zones ' 'No.of Detection and ,00~' No.of Switches No.of Gas Burners Initiating Devices `' No.of Ra Total No.of Air Cond. Tons 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❑ Conn iciPla 0 Other No.of Dryers Heating Appliances KW SecuriNot•f Systems:* es or Equivalent No.of Water , No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs +No.of Motors Total HP Teiecomman1 ations W No.of Devices or E4�at 0 rHa.R: _ Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical� Work: g,. 1 (When required by municipal policy.) b f�i" Work to Start: ).2' 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 inswwince 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 ❑ OTHER 0 (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: �/ ,� LIC.NO.: Licensee: 'r' °t/n e �,s=�Signatu . ,a,,,s45, LIC.NO.: i (If applicable, ex t"in t e lic a number line.) 3l Bus.TeL No.- ° 7C/ Address: ? `je"a/j n jQ,, F r f,'T�oy ©..2 S- c! Alt Tel.No.: /7 *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: ic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability i ce coverage normally required by law my signature below,I hereby waive this requirement, I am the(check one) owner 0 owner's agent. Owner/Age Signature Telephone No �3 -i PERMIT FEE:$ . The Commonwealth of Massachusetts ► =, �t Department of Industrial Accidents __ i'i 1 Congress Street, Suite 100 � _0_ A Boston, MA 02114-2017 Y .. www mass.gov/dia Y Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. f TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): /Pp, ' iV r..cc i')-7 ?"---7 Address: .7-`7 -54-'0)-) /424/ Lh r City/State/Zip: E //),,,L f M o.2-S,3e., Phone #: 5V 7 V/37! Are you an employer?Check the appropriate box: Type of project(required): 1,Q employer with 1 2, employees(full and/or part-time).* 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity.[No workers'comp. insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ' 10 Dg addition 4.❑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.FU'Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.1:I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.El Roof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] ; r *Any Annlir.»nt flintr1 At r enks nv if 1 mi+et�Icn fell n,r H, io -i.ai .ehn.i.;aa3.tb v '.er err ,.' n-...,n.,zaF, F;oI.iey.-y' Y..5 »..,,, _ ---- -.-. -- Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating su ' *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: /th# Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: /7 7 4,- ,off City/State/Zip:it /Stt /Zilr�.•-��'• D-719,26/V—..." 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 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 certi under the pains and penalties of perjury that the information provided above is true and correct. Signature � �j��-z.� �...-� � Date: �j O� Phone#: P'7 7`f /✓`_i 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#: