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Home My WebLink AboutBLDE-22-001563 Commonwealth of Official Use Only E ■ . / i�n' Massachusetts Permit No. BLDE-22-001563 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checke d Y [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:9/20/2021 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) 32 COUNTRY CLUB DR Owner or Tenant Susan McKenna Telephone No. Owner's Address 32 COUNTRY CLUB DR, 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 ❑ Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Miscl.work on first floor. Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires 8 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- ElNo.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I 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 Tons No.of Waste Disposers Heat Pump I Number I Tons I KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local 0 Municipal Connection 0 Other: No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of Devices or Equivalent Heaters KW No.of No.of Ballasts Data Wiring: Signs No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent 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 o er'ury,that the information on this application is true and complete. FIRM NAME: E F WINSLOW PLUMBING HEATING CO INC Licensee: RICH M MELVIN Signature Tel. NO.: 21829 (If applicable,enter"exempt"in the license number line.) Address:8 REARDON CIRCLE, SOUTH YARMOUTH MA 02664 Bus.Tel.No.: *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 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 4244(771i jGe__, � .Cata O ue l of M ss c� YSP S OfticlalUse Only�n '4` Permit No. 2Z ' �- li- 1- Department of fire ServicesafI -7/ BOARD OF FIRE PREVENTION REGULATIONS Oooupancy and14'ee Checked [Rev.9(0�� (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL ORKAll work to be performed In accordance with the Massachusetts Bleofrical Code C x u (PL. AS.1;2.RINT.tN DI OR TYPE A.LLfN. 'ONaTION ),527 cMR 12,00 City-or Town of: `/ Date: l Z Z `tp✓W4Otli' To the Inspector of By this application the undersigned gives notice of his or her intention to perform the eleotrical work described below, Location(Street&NNumber) 6 i-f _ 1 r Owned'or Tenant SUS !l Pi d N Gtt/is2(�Ll�� ZGK l{ Owner's Add Telephone No77( 230r'1�/�. Is this permit in conjunction with a building p unit? Yes ~ No ' heClcAppxopxiateEox) ) (7 l�tility Authorization No. 'BxistingService .Amps • / Volts Overhead —" --- —— �' Undgxd No.of Meters New Service Amps / 'Volts Overhead E NuxnberofE+eedexs and knpacity C Undgrd No,of Meters Location and Nature ofl'roposed Electrical Work: Sfi • Com.letioil o the ollowi 'table ins be waived b the ins.actor o Wires, otal No.of Ile cessed Luminaires �' No.of Ceil. Susp.(addle)Fans No.of Transformers KVA. No,of 3Lutnivazre Outlets No.of Hot Tubs Generators JC.VA. No,of Luminaires SwimmingPool Above --- In- 'o.o IMergency tg1-mg :rnd. :xnd. C Bane Units No.of.Re ceStacle Outlets No,of Oil Burners BXS E.ALARMS No,of Zones No.of Switches • No.of Gas Burners No.of Detect on and No.of Zanges xnitiatin• Devices No,of Air Cond. o to - No,of mastTons No.of Alerting;?evices Waste Heat Pump Nuxub,ez Sons `Jf'otals. x ,.•.,,..., NaDer of Self-Contained No.of Dishwashers Detection/Alertin:Devices Space/Area Heating KW LocaID Cfunicipal No.of Dryers ZIeatin .A liances• Connection Other Beating Appliances I Secur�ity'S sterns;* No,of Water' S No, of No.of Devices or g uivalent Beaters No, of DataWirin• Si ns Ballasts g% No,Hydx orriassage Bathtubs No.of Devices or E.uivalent No. of Motors Total Telecommunications ri g; OP ZI♦St< No,,of of'Dvices orS+.trivalent Attach additional detail if desired,or as required by the Inspector,of Wires, Estimated Value of Electrical Work: Work to Start; (When required byrounioipal policy,) Inspections to be requested in accordance with lV1ECRuie 10,and upon completion. INSURANCE COVI;RA.GE; Unless waived by the owner,.no permit for the performance of electrical work mayissue un the licensee provides proof ofliability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is hi force, and has exhibited proof of same to the permit issuing office, less "� CHECK ONE: 7NSU.RANCE 0 BOND h X certi ❑ Oq'�B• [] (Specify:) fy,wider the pains andpenallies ofpedury,Mat the inform/Ion on tlllr ap lication is irne and complete. NAM lulu; E,F, WINSLOW PLUMBING &HEATING CO,, i ' Licensee; RICHARD MELViN LZC,NO,;328'(0 M glapPlicable,erne%' "exempt"in the license number line.) Signature _ Addi'eSS; e REArtnON olftCLn SOUTH YARMOU --• LSC'NO,;2'I Sz9A 7t;,MA ezee4 Ega,Tel.'e.I.No„Go6�3sq.7_— *Security System Contractor•.picense required for,this work;if applicable,enter the license OWNER'S XNS171�ANCEA.It. No,; WAIVER; I am aware that the Licensee does not have the liability insurance coverage normally mally required bylaw, By my signature below,I hereby waive this requirement. l am the(check ode O quire Agent Signature owaexy,ner'S agezxt, Telephone No, ' E,F, Winslow Inspection Department email: inspections@efwinslow.com The Commonwealth of Mas,srachusetts r ®; Department of XndustrialAcciderzts s Office of Investigations NNNI Lafayette City Center 2 Avenue de Lafayette Boston,MA 02111-1750 'e°A` www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: E.F. WINSLOW PLUMBING &HEATING CO, INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508•-394.7778 Are you an employer? Check the appropriate box: Business Type(required): 1.I'N I I am a employer with 90 employee's (full and/ 5. n Retail or part time)* 6. 1 _tRestauraut/I3ax/Eating_Rstablishmetat • 2.1 1 I am a sole proprietor or partnership and have no 7 1 1 Office and/or Sales (ind real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non-profit 3.1 I We are a corporation and its officers have exercised 9. n Entertainment their right of exemption per c. 152, §1(4),and we have 10,n Manufacturing no employees. [No workers' comp.insurance required]** 4. We are a non-profit organization,staffed by volunteers, 11'n Health Care - with no employees. [No workers' comp.insurance req.] 12.0 Other . • *Any applicant-that checks box#1 must also till out the section below showing their workers'compensation policy information. Y*If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an. organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees'. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self ins.Lic.#1964A Expiration Date:01/01/2022 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under§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 faun 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. X do hereby cer -yr-ten c'the p Cins and penalties ofperjury that the information provided above is true and correct. Signature: Date: 01102/2021 Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# . Issuing Authority(check one): Z,—Board of Health 2.DBuildingDepartment 3E1City/Town Clerk 4.[Lic ensing Board 5.0Selectmen's Office 6,[(Other Contact Person: Phone#: • www.lnass.gov/dia