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Home My WebLink AboutBLDE-22-000425 oQJCommonwealth of Official Use Only filk,111 Massachusetts Permit No. BLDE-22-000425 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:7/22/2021 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) 37 DAUPHINE DR Owner or Tenant ROGERS DANIEL A Telephone No. Owner's Address ROGERS JANICE E,2 WEST VALLEY DR, CUMBERLAND, RI 02864 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: Kitchen/bathroom remodel 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 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 Equivalent No.of Water KW No.of No.of Ballasts Data Wiring: Heaters 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 ofperjury,that the information on this application is true and complete. FIRM NAME: DOUGLAS S VELIE Licensee: Douglas S Velie Signature LIC.NO.: 21245 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:6 SANDY MEADOW WAY, EASTHAM MA 026426104 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 0,UZ,t/ 7/2,341 � 4.; ��r� I�ILI�z I > o (.ommonwea[h of//Iaeeac 14 OfficiatelllUUsse Only ./y ;,0,,- .,, >it /�7 Permit No. epeirtment a ..titi Serviced Occupancy and Fee Checked (,) --1 Z '•, BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] u j i f o (leave blank) ce APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK p m m All work to be performed in accordance with the Massachusetts Electrical Code( EC), 27 CMR I2.00 'LEASE PRINT IN INK OR TYPEALL INFOR�TION) Date: 7 ' 2O 2 City or Town of: KAI00 I n To the In ctor f Wires: By this application the undersignedEPaZJl es noti)off his or her intention to perform the electrical work described below. _� Location(Street&Number) hi of Nke Owner or Tenant FIftj Y Ai"Q-1,(X Telephone No. -* Owner's Address 3-r 044 t.'i t`16 Is this permit in conjunction with a building permit? Yes [Vr No ❑ (Check Appropriate Box) t Purpose of Building Utility Authorization No. .� Existing Service Amps / Volts Overhead El Undgrd 0 No.of Meters New Service Amps / Volts Overhead 0 Undgrd 0 No.of Meters p Number of Feeders and Ampadty Location and Nature of Proposed Electrical Work: 1111,4 jl 01 N,i ty C Q 00 a L Completion of the following table my be waived by the Lector of Wires. ti.W No.of Recessed Luminaires No.of Cell.-Snap.(Paddle)Fans No.of Total Transformers KVA CANo.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires S�min Above In- No.of Emergency Lighting g Pool grnd. ❑ grad. ❑ Battery Units .t No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones 1. No.of Switches No.of Gas Burners No.of Detection and Initiating Devices tal t 1,' No.of Ranges No.of Air Cond. To No.of Alerting Devices ns Heat PumpNumber Tons KW No.of Self-Contained No.of Waste Disposers ..._.__.__..... Detection/Aler�Devices Totals: ' _ No.of Dishwashers Space/Area Heating KW Local❑ ML°nec 0 () Contion tiler No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water , 'No.of No.of Data Wiring: Heaters Signs .Ballasts No,of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP 'Telecommunicationsringg 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: 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 cov ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [ BOND ❑ OTHER 0 (Specify:) I certify,ander the ins andpen hies ofperjury,th the information this applica is true and complete. FIRM N 12-tm, N. • LIC.NO.: 2'124�.. Licensee: t.t Signature LIC.NO.: 0 (If applicab ter"exempt"in the icense number line.) Bus.Tel.No. — 31/ 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 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:$ 7t`5'' I o The Commonwealth of Massachusetts I Department f Industrial Accidents ='"�- 1 Congress Street, Suite 100 Boston, MA 02114-2017 •:� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A Iicant Information Please Print Le 'b1 Name (Business/Organization/Individual): t4C i Address: 414 City/State/Zip: 49' ' � 1 0 ,„r . Phone#�� 2--b 5= 1.3 Are you an employer?Check the appropriate box: 1.i am a employer with employees(full and/or part-time).* Type of project(required): ?.❑I am a sole proprietor or partnership and have no employees working forme in 7. ❑New construction any capacity.[No workers'comp.insurance required.] g• ®Remodelirig 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition • ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance? 1 •❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees. 14.❑Other [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 $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. such I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. . Insurance Company Name: rV 5-k • Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: C 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 day against the violator.A copy of this statement may be forward ations of the DIA for insurance a y ed to the Office of Investi coverage verification. . A g I do hereby certify u ,i - the p/'nsC nd e 11 P ti• of perjury that the information provided above is true and correct Si•nature: Ar,_ i ` � � � Date: � � Phone#: �, G Official use only. Do not write in this area,to be completed by city or town official City or Town: Issuing Authority(circle one): Permit/License# 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: