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Home My WebLink AboutBLDE-22-000268 Commonwealth of Official Use Only _ Massachusetts Permit No. BLDE-22-000268 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:7/16/2021 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) 111 CROWELL RD Owner or Tenant LADIN EDWARD L TRS Telephone No. Owner's Address LADIN KATHRYN C, 2 LEAFY LN, LARCHMONT, NY 10538 Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. 46i-4. Existing Service Amps Volts Overhead 0 Undgrd 0 1 14 g New Service Amps Volts Overhead 0 Undgrd 0 o.of i • Number of Feeders and Ampacity Ir.,4Location and Nature of Proposed Electrical Work: Install security system. Completion of the following table may be wr t , ," - 0 ec of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Transformers *01476 No.of Luminaire Outlets No.of Hot Tubs Generators 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 Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alertine Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal Connection 0 Other: No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Ballasts Data Wiring: Heaters Signs 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: Paul J Wright Licensee: Paul J Wright Signature LIC.NO.: 1145 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:8 DEERFIELD RD, MEDWAY MA 020532206 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: $190.00 • C 04. 1I2 'RECEIID //�� QQ// Commonwealth �j�� / } =*___ c� 0��/77//adaachu�ef�a Official Use Only JU L 1 aGJePartmerat o�}ire�ervice5 Permit No. JUL _ o —` Occupancy and Fee Checked BUILpiNG DEP , . 'NT BOARD OF FIRE PREVENTION REGULATIONS By; __ [Rev. 1/07] (leave blank) A5-LICATION 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: `1 /5 MEC 1 City or Town of: Web-- 11A(1-oixi-N ctr of Wires: By this application the undersigned gives notice of his or her intention to performe e eleIns ct ical work described below. Locatie i;(Street&Number) I11 Cry\ r-c Owner or Tenant L i r G41..L0 Owner's Address Telephone No. J AC�-)E Is this emit in conjunction with a building permit? Yes Q No ❑ (Check Appropriate Box)Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (tiy��-Ott 6 _ Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Sus No.of Total p.(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 j FIRE ALARMS [No.of Zones No.of Switches , No.of Gas Burners j No.of Detection and Initiating Devices No.of Ranges . No.of Air Cond. Total Tons I No.of Alerting Devices 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 Municipal _ �� Connection Other No.of Dryers Heating Appliances KW ecurity systems: No.of Wad,�r�T No.of No.of Devices or Equivalent Hdters' KW No.of Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Telecommunications Wiring: Total HP No.of Devices or Equivalent OTHER: O- ctAk C,,'`PT Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value f El'ctrical Work: s Cf✓ (When required by municipal policy.) Work to Start: / /J i 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 ❑ I certify, fp, under the pains and penalties o era that the information on this application is true and complete. FIRM N ' Licensee: Y f \ U \ I,?i r. LIC.NO.: C ice_ * Signature I app licabl nter ` empt"in the license number line) LIC.NO.: 0y f Address: OC `- Vyl`01.0 ( R bE� Bus.Tel.No.: G _�; ;= 13 Alt.Tel.No.: *Per M.G.L. c. 147, s. 57-61,security work requires Department of Public Safety"S"License: Lic. No. Ji 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 a•ent. Owner/Agent Signature _ Telephone No. PERMIT FEE: $ j(' r ' q The Commonwealth of Massachusetts • w_ M� t Department of Industrial Accidents =;®1 Office of Investigations 1'' _ f` Congress Street, Suite 100 , Boston,MA 02114-2017 Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers s/Contractors/Electrici A licant Information ans/1'lumbers Name (Business/OrganizatioMndividual):—LA_____ _= �Pt, Please Print Le ibl Address: -- � I City/State/Zip:M�lj n CJ , Are you an employer? NI Phone#: �105 �� 13 Check the appropriate box: ----- Are pg I am a employer with 3 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors Type of project(required): 2•El I am a sole proprietor or partner- listed on the attached sheet. New construction ship and have no employees These sub-contractors have ❑Remodeling working for me in any capacity. employees and have workers' 8. ❑Demolition [No workers' comp, insurance comp.insurance.$ 9. Building addition required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3•❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL 11.E]Plumbing repairs or additions insurance required.] 1 c. 152, §1(4),and we have no 12.0Roof repairs employees. [No workers' 13.0 Other 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 *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or employees. If the sub-contractors have employees,theyaffidavit indicating such. must provide their workers'com not those entities have am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site i Insurance Company Name: `.\-k �1il.` i Policy#or Self-ins. Lic. #: ��(� Expiration Date: n Job Site Address: 111 CR.0w (._ I Attach a copyCity/State/Zip•W• I "IC) ►Yl� �� of the workers'compensation policy declaration page(showing the policy number and expiration Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOPp on datf. of up to$250.00 a day against the violator. Be advised that a copyp tton of criminal penalties of a Investigations of the DIA for insurance coverage verification. of this statement may be forwarded to the Office of WORK ORDER and a fine I do hereby erti u er the airs and penalties o fperjury that the information provided 'bov is true and correct. Si ature: Phone#: Date: 17 J� 1 Official use only. .Do not write in this area,to be completed by city or town official. City or Town: Issuing Authori Permit/License# I.Board of Health(2rBuild Building Department 3.Ci 6.Other ty/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Contact Person: Phone#: