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HomeMy WebLinkAboutBLDE-21-003008 Commonwealth of Official Use Only Massachusetts Permit No. BLDE-21-003008 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:11/27/2020 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) 17 AUNT EDITHS RD Owner or Tenant WILSCHUT ROY Telephone No. Owner's Address DRAPER DABNEY AMES, 98 CANTERBURY WAY, BASKING RIDGE, NJ 07920 P Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check A 1 p Purpose of Building Utility Authorization No. a Existing Service Amps Volts Overhead 0 Undgrd 0 i o. i l` • •rs AA, New Service Amps Volts Overhead 0 Undgrd 0 pi, •OWL, ' Number of Feeders and Ampacity ' , Location and Nature of Proposed Electrical Work: Lighting,outlets and switches in basement. o Completion of the following table may be waived by the In 00 Wires. No.of Recessed Luminaires 18 No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets 1 No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool rnd e 0 In- CINo.of Emergency Lighting g grnd. Battery Units No.of Receptacle Outlets 5 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 9 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting 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 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: (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: Licensee: Jon T Moreau Signature LI NO.: 22967 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:9 Redberry lane, MARSTONS MILLS Ma 02648 *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt.Tel.No.: OWNER'S INSURANCE WAIVER:I am aware that the License does not have the liability insurance coverage normally required by law.But 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 I Comnwnweaith.o`Maidachadette Official Use Only lii `' Apartment cc77 Permit No. CZ/ -3Uttt1 �UApartment o`...tire serviced m 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: 11/18/2020 City or Town of: South 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) 17 Aunt Edith's Road Owner or Tenant Roy Wilschut Telephone No. Owner's Address Same Is this permit in conjunction with a building permit? Yes ❑ No V (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead n Undgrd n No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Wiring lighting, outlets and switches in basement Completion of the following table may be waived by the Inspector of Wires. Total No.of Recessed Luminaires 18 No.of Ceil:Susp.(Paddle)Fans Tf Transformers KVA No.of Luminaire Outlets 1 No.of Hot Tubs Generators KVA No.of Luminaires 3 Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets 5 No.of Oil Burners (FIRE ALARMS No.of Zones No.of Switches 9 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of AlertingDevices 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 Equivalent No.of Water KWNo.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: 5720.00 (When required by municipal policy.) Work to Start:ASAP 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 perjury,that the information on this application is true and complete. FIRM NAME: Coastal Mechanical LIC.NO.:22967A Licensee: Jon Moreau Signature it,7/444,azz LIC.NO.:8082A1 (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.:508-737-8747 Address: 21 L Fruean Ave-South Yarmouth, MA 02664 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)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $75.00 • The Commonwealth of Massachusetts Department of industrial Accidents • I Congress Street,Suite 100 '€__111 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Coastal Mechanical Address: 21 L Fruean Ave City/State/Zip:South Yarmouth, MA 02664 Phone#i: 508-737-8747 Are you an employer?Check the appropriate box: • Type ol project(required): 1.1V1 sin a employer with employees(full and/or part-time).* 7, 'Mew construction 2,0 I am a sole proprietor or partnership and have no employees working for Inc in 8. j4emodeling any capacity.[No workers'comp.insurance required.) 3.❑l am a homeowner doing al l work myself:[No workers'comp.insurance required.)t 9. ❑Demolition 10❑Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property, l will ensure that all contractors either have workers'compensation insurance or arc sole 11, lectrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.0lam a general contractor and I have hired the sub-contractors listed on the attached sheet, 13.0 Roof re Airs These subcontractors have employees and have workers'comp.insurance.t ❑ p 6.0 We are a corporation and its officers have exercised ihcir right of exemption per MCI,e. 14. Other HVAC 152, 1(4),and we have no employees.(No workers'camp.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 die sub-contractors and state whether or not those entities kayo 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: AIM Mutual Policy#or Self-ins.Lic.#: WMZ80080074082020A Expiration Date: 01/04/2021 Job Site Address: 17 Aunt Edith's Road City/State/Zip: South Yarmouth, MA 02664 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$250,00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: /l%etarl Date: 11/18/2020 • Phone#: 508-737-8747 • Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2,Building Department 3,City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: • i .COMMONWEALTH OF nuSSACHS DIVISION OF PROFESSIONAL LICENSURE EL CTRICIANS ,.. , ISSUES TIi .FOLLOWfNG ICE SE -- r RICAL$USIN.E:SS. COASTAL PLUMBING<AN D HEATING iM . 1 FRJEAN LLG . oY •SOUTH AiOi H, '-f MA 026.6,4-,1671 - J (31I2022 963629 LICENSE NUMBER `a s ': • EXPIRATION DATE SERIAL NUMBER CONTROL# IMPORTANT " If your license is lost,damaged or destroyed;is inaccurate;or needs to be corrected,visit our web site at mass.gov/dpl for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. • This license is subject to Massachusetts General Laws and regulations.Your license is a privilege,and cannot be lent or assigned to any or entity license on your person or posted as under equiredtby law andy of law. /or this regulations. • Commonwealth of Ma usetts Division of Professionif4tp‘ e Board of State E2mareditfraer4ians -- JON TH v = T� W 9 REDS 'x` • . MARSTO Master ElecrOatR l • 22967-A 07/31/2022 y 4sJ' '77-s° 0075082 License No. Expiration Date. Serial No. Client#:764315 2COASTALPLI ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 20 BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT;If the certificate holder is an ADDITIONAL INSURED,the olicy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on p this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER The Hilb Group of N.E.dba Dowling&O'Neil Insurance Agy • PHONE E E-MAIL C M:508 775-1620 F,vc No: 5087781218 P.O.Box 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE Mutual Insurance Company INSURED Coastal Plumbing&Heating LLC INsuRER B;A I.M. ], � Dba Coastal Mechanical INSURER c:Safety Insurance Company "Mallill '+ 299 Whites Path INSURER D: South Yarmouth,MA 02664 — COVERAGES CERTIFICATE NUMBER: wsuRER F: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD REVISION NUMBER: INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL A ©COMMERCIAL GENERAL LIABILITY iNSR r POLICY NUMBER MMlDDY EFF POLICY EXP MKLV1 PBC000737 11/04/2020 01/04/2021 EACH OCCURRENCE 1111111 ��CLAIMS-MADE �X OCCUR $1 000 000 81/PD Ded:5,000 PR 1SEs�Ea o� n� $1 DO 000 MED EXp(Any one person) MIIIIMIIIIIIII GEM.AGGREGATE LIMIT APPLIES PER: PERSONAL&Any INJURY III $1,000,D00 POLICY El JECT LOC $2,000,000 ■OTHER PRODUCTS-COMP/Op AGG $2,000,000 AUTOMOBILE LIABILITY , IIIIIIIIIIIIIOEINIIIIIIIIII 5906835 11/04/2020 01/04/2021 COMBiNEDSINCLELIMIT .ANY AUTOEaaccident 1,000,000 II OWNED ©SCHEDULEDIII BODILY INJURY(Per AUTOS ONLY AUTOS person) aIIIIIIMM HIREDE ONLY I IIII : NON-OWNED BODILY INJURY(Per accident) PROPERTY DAMAGE Per accident A III UMBRELLA LIAB III OCCUR , ©EXCESS LIae MKLVI EUL102213 11/04/2020 01/04/2021 EACH OCCURRENCE © CLAIMS MADE $1 000 000 III DED III RETENTION$ $1 000 000 IIIWORKERS COMPENSATION AND EMPLOYERS'LIABILITYY/N WMZ80080074082020A t 1/0412D20 Ol I04/2021©OAFFICERRO/MEMB REEXCLUDEEED CUTIVE— l 1 _ ■ (Mandatory in NH) N E.L.EACH ACCIDENT Ryes,describe under $1,000 000 DESCRIPTION OF OPERATIONS below E.L DISEASE-EA EMPLOYEE $1 000 000 111111111.1111111111111111111111111111 E.L DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Hall THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 134 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2096/03) 1 of 1 The ACORD name and logo are registered marks of ACORD 2015 ACORD CORPORATION.All rights reserved. #S251644/M251588 LS1