BLDE-22-002849 Commonwealth of Official Use Only
_ ., 4) Massachusetts
Permit No. BLDE-22-002849
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:11/17/2021
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) 24 OLD CASTLE RD
Owner or Tenant LYONS CAROLYN COX Telephone No.
Owner's Address C/O 0,''?^' YN L Rf f N ENE PLEASANT STREET COURT, CHARLESTOWN, MA 02129
Is this permit in conjunction w" a building pert tft? 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: Remodel basement
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
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 0 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 of perjury,that the information on this application is true and complete.
FIRM NAME: MICHAEL S SOBY
Licensee: MICHAEL S SOBY Signature LIC.NO.: 10097
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address:66 Lake Dr,Orleans MA 02653 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
004,(A54 << A)(2.1 f.
Ai f`_,(
I
Commonwealth o/!/la3sachu.e(L4 Official Use Only
1► t 2)eparlmenl o� lire�ervice3 Permit No. C�Z� 7----
!f @y 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( EC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: (( 1(e i
1-1
City or Town of: A( To the Inspector of Wires:
By this application the undersigned : yes notice of his or her intention to perform the electrical work described below.
Location(Street&Number) •„-, `o ,;.:;�,'rt ,,c.4 d(d carykt. 2d
Owner or Tenant Caro( A SeAr-fn f Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No.- (Check Appropriate Box)
Purpose of Building S it f p_freur�,��5 ,,el.e,1.(�Q� Utility Authorization No,
Existing Service mps 0 / Volts Overhead C Undgrd ❑ No.of Meters
New Service Amps / Volts Overhead C Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: €Ci Air p / 60.77 nat.)
' , ' ,02(1/t.S4d eacmp.th--
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:pf 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
Li No.of Detection and
No.of Switches No.of Gas Burners Initiating Devices
No.rof Ranges No.of Air Cond. Total No.o f 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 cal❑ Municipal Connection ❑
Lo Other
`No.)pf Dryers Heating Appliances KW Security Systems:*
No.of tevices 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: '16t 000 (When required by municipal policy.)
Work to Start: I(i f6/�' Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE C V RAGE: 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 0 (Specify:)
I ceri'tfy,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: Soby One Home Services LLC LIC.NO.: 10097B
Licensee: Michael Soby Signature "`Z- - s LIC.NO.: 10097B
(If applicable,enter "exempt"in the license number line.) Bus.Tel.No.:633-762-9663
Address: 9 New Venture Dr.Unit 4,South Dennis,MA 02660 Alt.Tel.No.: 774-216-0935
*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
611
Signature Telephone No. PERMIT FEE: $ i�
i
l
`• The Commonwealth of Massachusetts
="= Department of Industrial Accidents
; Office of Investigations
_71= 600 Washington Street
• _�
Boston,MA 02111
WWW.mass.gov/dia
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information PIease Print Legibly
•
Name(Business/Organization/Individual): °Soby One Home Services LLC
•
Address: 9 New Venture Dr.Unit 4
City/State/Zip: South Dennis,MA 02660 Phone #: 774-216-0935
Are you an employer?Check the appropriate box: Type of project(required):
1.® I am a employer with V 4. ❑ I am a general contractor and I
have hired the sub-contractors
employees(full and/or part-time).*
6. New construction
listed on the attached sheet. 7. ❑Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub contractors have g, ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp. insurance.f 9. AI
uiiding addition
required.] 5. ❑ We are a corporation and its 10.Fe lectrical repairs or additions
officers have exercised their 11.0 Plumbing repairs or additions
3.❑ I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.)
'Any applicant that checks box NI 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 the sub-contractors and state whether or not those entities have
employees. lithe 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.Lie.#: WCC50050242272021A Expiration Date: January 25,2022
Job Site Address: v l 6 j4 0,04 ed City/State/Zip: f n'�YQ',�2(or(
p v
Attach a copy of the workers'compensation policy declaration page(showing the policy ber and expiration date).
Failure to secure coverage as required under Section 25A of MGI,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 form 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.
I do hereby cert under the pains and penalties of perjury that the information provided above is true and correct.
Signature: "`2-7 3- Ulf
J Date: f.
Phone#: 774-216-0935 f
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):
' I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: • Phone#: