BLDE-22-006129 Commonwealth of Official Use Only
Massachusetts Permit No. BLDE-22-006129
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:4/26/2022
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) 164 FOREST RD
Owner or Tenant Richard Croteau Telephone No.
Owner's Address 17 WESTFIELD DR, HOLLISTON, MA 01746
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: Wiring for sun room.
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires 4 No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets 4 No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above 0 In- ❑ No.of Emergency Lighting
grnd. grnd. Battery Units
No.of Receptacle Outlets 4 No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches 3 No.of Gas Burners 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
No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other:
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Eauivalent
No.of Water KW No.of No.of Ballasts Data Wiring:
Heaters Siens No.of Devices or Eauivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Eauivalent
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: Roger Poitras
Licensee: Roger Poitras Signature LIC.NO.: 14319
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address:PO BOX 176, ROCHESTER MA 027700176 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
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ei f�"% Permit No.
�1_.' .2 epartment o ire.Services
.�== _=. Occupancy and Fee Checked
APR BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
BUILDING DERpf PLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
By f1I�rL
Ail 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: t/ —a /- Do D 2
City or Town of: ypi l2 M o u j/.1- 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) /to 9 f j R c S r R n A D
Owner or Tenant R i r_ 444.R r, C R a I C4 i) Telephone No.NJ-Y39-44)S6
Owner's Address /6 y tD A CS 7 A
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building A G Si S/2 icL,C _. Utility Authorization No.
Existing Service a en Amps last l a Aia Volts Overhead Ye2r Undgrd❑ No.of Meters 1
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity a _/j—A?n>Q ,I-F c T C i izc v t T ' i
Location and Nature of Proposed Electrical Work: (u i/Z>: s U hj goo r,,
Completion of the following table may be waived by the Inspector of Wires.
NNo.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans of Total
y T Trr ansformers KVA
No.of Luminaire Outlets Z4 No.of Hot Tubs Generators KVA
No.of Luminaires L Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting
( grnd. grnd. Battery Units
No.of Receptacle Outlets L( No.of Oil Burners FIRE ALARMS No.of Zones
No.of SwitchesNo.of Gas Burners No.of Detection and
3 Initiating Devices
No.of Ranges No.of Air Cond. Total Tons No.of AlertingDevices
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 i
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW 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: a cat", O O (When required by municipal policy.)
Work to Start: E/d,/)e,1 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
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 perjuiy,that the information on this application is true and complete.
FIRM NAME:k.,P EC,LTx I G C 4 . .4"� LIC.NO.: / j 3 /574-
Licensee: JA d G c& A4 i r' 4S Trt Signature LIC.NO.:/el 3/9g-
(If applicable enter "exempt"in the license number line.) Bus.Tel.No.:3 3;a,Q= 9 Li 3 7
Address: Jet 4 /;O X / 7 C ADG/ C S re A. ri 4. 6?---. ) C Alt.Tel.No.:
*Per M.G.L. c. 147,s. 57-61,security work requires Depaitnient of Public Safety"S"License: Lic.No. /Lf 3/14
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: $ 7S v
Signature Telephone No.