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HomeMy WebLinkAboutBLDE-22-06052 Commonwealth of Official Use Only Massachusetts Permit No. BLDE-22-006052 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checkedo [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:4/21/2022 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) 16 ACRES AVE Owner or Tenant Eric Rosenthal Telephone No. Owner's Address 16 ACRES AVE,WEST YARMOUTH, MA 02673 Is this permit in conjunction with a building permit? Yes ❑ 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: Fan/light&switches in master bathroom&move light into closet&receptacle 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 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 Gas Burners No.of Detection and No.of Switches Initiating Devices No.of Air Cond. Total No.of Alerting Devices No.of Ranges Tons Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices al Munici No.of Dishwashers Space/Area Heating KW Local ❑ Connection 0 Other: HeatingAppliances No.of Dryers pp KW Security Systems:*No.of Devices or Eauivalent No.of Water KW No.of No.of Ballasts Data Wiring: Heaters Signs No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Eauivalent 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: Todd A Higgins LIC.NO.: 13438 Licensee: Todd A Higgins Signature Bus.Tel.No.: (If applicable,enter"exempt"in the license number line.) Address: PO BOX 1958, ORLEANS MA 026531958 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: $75.00 PIX-re, (/7/7 i4 . 44c , 121)12,)..r.€ Commonwealth. �//� / Official Use Only / (..ommoncueal�o���/a��achu�alfe f� r. / c�r� Permit No. ��' I! a T epartment of Sire�ervice3 : i 5.4 Occupancy and Fee Checked ,,� � ' BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (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 IN INK OR TYPE ALL INFORMATION) Date: V / `"- z City or Town of: ).1/2-1140 ./r}-/ 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) /G 4 G, A V 6 ' Owner or Tenant ��tC i2 $ .t" 14A I' Telephone No.72Z g/4 7 Owner's Address 4 /`- Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of BuildingSv-i 'il - CZe,'D Z Utility Authorization No. Existing Service MO Amps /f /23C,Volts Overhead ii Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd 0 No.of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: A of, ,, j f-/ FAN/ I.-(c.,.(-FT- -/---emu// I'Z- 1 by 4,5 0}-7 ol') eic t--cctf j—/Ptr O c-L.C,5L� -I- f /ZL!'V '-c-C Completion of the followin&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 Above In- No.of Emergency Lighting No.of Luminaires Swimming Pool grnd. ❑ grnd. ❑ Battery Units 9 No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones 1 No.of Detection and 1 No.of Switches No.of Gas Burners Initiating Devices No.of Air Cond. Total No.of Alerting Devices No.of Ranges Tons 'Heat Pump Number Tons KW No.of Self-Contained C\ No.of Waste Disposers Totals: Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other ►. Heating Appliances ICi�' Security Systems:* No.of Dryers No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KWSigns 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. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 7-l5 2.2—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 insurance including"completed operation"coverage or its substantial equivalent. The 11 undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. 41 CHECK ONE: INSURANCE 12 BOND ❑ OTHER ❑ (Specify:) 1'1 I certify,under the pains and penalties of perjury,that the information on this application is true and complete. ® FIRM NAME:'/, l�I G� �i l/�� C•�L C-�a2-C,� LIC.NO.:/9 43 - 3 V QP '4- H/C.Gl/$ Signature /�' LI 0:e�-li�i `f r 9 Licensee:� � ��`'���6" �?J. V (if applicable e�enter "exempt"in the license number line. j Bus.Te. o. (� Address: /', 0-13 D� j 9S- 4`�/t/i 40 Aft.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. a 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 0 owner's agent. Owner/Agent Telephone No. I PERMIT FEE: $ Signature 1 ne c.ommunweuicn o/ iviussucnuseus „� Department of Industrial Accidents . 4. -- 1i�ITali 1F Office of Investigations ~ '_ 600 Washington Street _ Boston, MA 02111 >-aLi-'' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): IT,. 74 f /tam//4s 1---:: e—C--712—/C_ _ Address: P 0 ._23o, /7.S City/State/Zip:Q fL C.04,0\-1-5 104 4' 6.7.�f,I'hone #: c�` P-3 7-C -?5 Are you an employer? Check the appropriate box: Type of project(required): 1.°K/ I am a employer with 1 4. ❑ I am a general contraCtc r` n I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' p h' 9. ❑ Building addition [No workers' camp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.n Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other 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: 4_ 1 -1)- wcC.---c(2 �3 Policy#or Self-ins. Lic. #: U G 7 �© Expiration Date: / ` 3' Job Site Address: /6 A /2L G - City/State/Zip:/AL 2✓flou73-t Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature:,7— Date: / r 22-- 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. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: —