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Home My WebLink AboutBLDE-22-005269 Commonwealth of Official Use Only ' AL"• 'i Massachusetts Permit No. BLDE-22-005269 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:3/22/2022 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. / O Location(Street&Number) 212 CRANBERRY LN 73 2 - W� - 4'93 Owner or Tenant GUNDAKER BRUCE F Telephone No. Owner's Address GUNDAKER ANN MARIE,51 STIRRUP DR, FREEHOLD, NJ 07728 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: Installation of two free standing lights in yard. 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 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 Switches No.of Gas Burners No.of Detection and Initiatine Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Ton No.of Waste Disposers Heat Pump Number Tons J KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers • Space/Area Heating KW Local 0 Municipal 0 Other: Connection 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: Siens 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: Signature LIC.NO.: (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address: 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 F E:$50.00 4 W4 * - (4? 3 _c RECEIVED MAR 2 I 2 Com,naonwea�01 Via�eacliudatfs Official Use Only / "1 - "0t c� cc�/ Permit No. 2Z,,�L BUILDING 1 . : N T .tJsparinsani o f Jirs Serviced 9157 Fly_ `i " — Occupancy and Fee Checked ,, :OARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) j APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CM (MEC),577 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 03 /a 1 j2.022 City or Town of: So> V Ye,-„,-- „r,Qv c\g. To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. V Location(Street&Number) 2,I z. (=c-cA..Y,c e,r-r-y Lco...v.e. L Owner or Tenant (3r,j r et. r- G v,r.A,c.,\e r- Telephone No.(732)b 90- 4 93.7 Owner's Address S 1 S t i r r-1/44•i> U r•:.te: V"r c d Is this permit in conjunction with a building permit? Yes 0 No 12 (Check Appropriate Box) Purpose of Building Utility Authorization No. c Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd 0 No.of Meters Z Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: _ 5 c 0.1 w o 1 a Inn p Pe.s. .5 ►s-, -yet_rct VI Completion of the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total CZ Transformers KVA Qt No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Q Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting grnd. grnd. Battery Units "-1 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 11,1 No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW 'No.of Self-Contained Totals: Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local 0 Municiponnection 0 other C No.of Dryers Heating Appliances KW Security Systems:* No,of Devices or Equivalent No.of%Dater 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: 4 Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: •• 60O (When required by municipal policy.) Work to Start: 3/2.1/2d Z.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 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 penas of perjury,that the information on this application is true and complete. FIRM NAME: iz (to w C.1 4..O; aLv 7Le.., w e r� r�y s e� LIC.NO.: Licensee: Signature LIC.NO.: (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.• Address: 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 . the Licensee does not have the liability insurance coverage normally required by la signature below,10 0 . - irement. I am the(check one.'owner ❑owner's agent. Owner/AgAK 5 D- Signature _�! , . I ne No. 3 a PERMIT FEE: $ 00 00 coth N. o W w oo C N o co..-1 O97', m v 0000 0 M rn v o r `I VI- to O co .--1" LA 01 - N In a ,441 - O a0 co � • 2 N N 00 00 I� N M 1� N ^ M L O 0O CO In N N `Y• 10 .10 N O .00 a. (.0 •-i 00 00 N• ry) IM1" e�-•1 N M 0• ..O N "M in ..'w., In- 0 1 a• .. N N .. : : : : : : : : : "' . ey N N 2 2 Z - " -Z E- Z aaJ+ av+ aai+. Y ;r ti, C O O O 0 0- c)_0m a) Np 0Qct. Qso. CZ) c) p a CI p ns pa' v v do.) �p p CI ppv> 0 E a' v E a' E— a EE _ Q" E E E a' EE E E E 000 : I-1 o a a 0 0 a _ _ __ _ _ = = _ _ _ cu -0 N N-. N N ,N N N " " y o O O O N N fN ul :\\ \ \ \ M 4a ry N M M M M d O o CO a Io m v ;a . a o oE 4 . Hp "mo v Nv 0" O O N NU U_ � O 111 4, U" a. a �" C ,Jh_0 C N N U O - a' N _c Od - ,C I— a:: G L .. -01 a�-1 .N-1 Q .co 10 "C 10 V to s tea,ffi co In a a' v -0 a' a' 10 a ai as u ai > > m cn m N a • :: aJ o m '> 3 O a�i v v v 3 0 - a) is L U o`ro N m m 3 N p v v L as c CO D > m x x 0 6 w = 0 ti4 m a d a a •c . m v �.: a a C m T >. 2 C7 . 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H i � I 3 � f A I � t t VF- B ��2 V _ ��, • The Commonwealth of Massachusetts L Department of Industrial Accidents = - 1 Congress Street, Suite 100 , II f a Boston, MA 02114-2017 www.mass.gov/dia gov/dia �5� ` Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (B-aSifiesk/Organs i dividual Br-v c. - P, G v'-aok. r cs Address: 51 S-6; ,--i— > tc- tv� City/State/Zip: Fr.C-=. ro I d , N A a 7/2 q Phone#: Ll s-2.) <`,v -- 4 ' 3 5' Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 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. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.�� I am a homeowner doing all work myself. t 9. ❑Demolition y [No workers'comp.insurance required.] I am a homeowner and will be hiring contractors to conduct all work on my1 O Building addition 4. ❑ property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.1gElectrical 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 These sub-contractors have employees and have workers'comp.insurance.x 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no 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: Policy#or Self-ins.Lic.#: ) inDate: Job Site Address: City/State/Zip: 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 hereb ' under th, , d pen, ties of'er'u. that the information provided above is true and correct. Signature Date: 03/2.1/Z022 Phone#: L _ 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#: