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Home My WebLink AboutBLDE-21-007470 Commonwealth of Official Use Only fi_. Massachusetts Permit No. BLDE-21-007470 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:6/23/2021 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice o1 his or her intention to pertorm the electrical work described below. Location(Street&Number) 160 WOOD RD I.(4 Up Q ,M Cov -ty Owner or Tenant .Sad & Telephone No. Owner's Address A' . ..-.=-_ - -.r. -- -- _ - D-:-.,;.w..=ur:""c=-----'"` 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: Remove range receptacle. 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/Alertinu Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal Connection ❑ Other: No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Siens 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: (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 ❑ OTHER 0 (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Jack W Griffin Licensee: Jack W Griffin Signature LIC.NO.: 418 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:26 JOANNA DR,S YARMOUTH MA 026641339 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 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: $80.00 • IL\ Comnsontoemeg oi Maaacluuseti4 Official Use Only 0 nit No. ---'°2-5k. —1 Cf--2 0 2eparinseni ot.7ire_S'e Pcn ruice4 I I:is7 1 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( C),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFOAMATION) Date: 026/02/ City or Town of: VAKA701171" To the 1 pect of Wires: By this application the undersign gives) notice of his or her intention to perform the electrical work described below. Sr 1 Location(Street Number) /6.6 ,12 Owner or Tenant fiy Opp c ,,,dy ,,,,_A e. Telephone No. 4 1 k•\ Owner's Address \._ Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. . v Existing Service Amps / Volts Overhead 0 Undgrd 0 No.of Meters New Service Amps / Volts Overhead 0 Undgrd 0 No.of Meters al Number of Feeders and Ampacity III' Location and Nature of Proposed Electrical Work; Ren f-v K A lette.„ jOiti7 4 i 5€40.4101t) Co rsi pkiZ - ..*., Completion of the followin&table may be waived by the lnspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans sio.of Total Transformen KVA No.of Luminaire Outlets 4c. No.of Hot Tubs Generators KVA 1--1 No.of Emergency Lighting co No.of Luminaires ,......„...,,,.„„, Above ri In- °'"'"" as`"‘" ern& L'I grnd. L'a Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices Total No.of Ranges No.of Air Coml. Tons No.of Alerting Devices Heat Pump Number.Tons _.IKW ... 'No.of Self-Contained No.of Waste Disposers Totals: T Detedion/Alerting_Devices No.of Dishwashers Space/Area Heating KW Local 0 Cl:ntlts 0 Mer No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water No.of No.of ICW Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Tel Wiring: No.Bydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: db Attach additional detail(fclesireih or as required by the Inspector of Wires. Estimated Value o El trical Work: / ) — (When required by municipal policy.) Work to Start:6 02/ ,2 I Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE 0 FtAGE: 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 e is in force,and has exhibited proof of same to the permit issuing office. c274 CHECK ONE: INSURANCE BOND 0 OTHER 0 (Specify:) I cer*,under the Lus and FIRM NAME: etC.k. C.,o 1-penalties of;pfilsoy,that the information on this application is true and complete,.A , 11-,A) LIC.NO.: /Vie Vii Licensee: 4id Signature LIC.NO.:hr d 6—97 9 Of applicable,4nterempt"in the license nupper lined Bus.TeL No.;97T- Y75- cgArtt,t/ Address: r--1 1609 14 A-4- DK 3 .1 A(0110t)ti1 40 4POV Alt.TeL No.: *Per M.G.L.c. 147.' s.57-61,security work rewires Department of lic 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)0 owner 0 owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: $ .'r titi mte' x rt aq �v m - k. 4 s a ' s ,.:; a- fix ,;v . 3 a rZ ' xy • .` • a /(1.1 F - ; $ ul I ..„,„, 40 f d` r, n } s • � - r o0 "''''''''' , ;« t • ^• _ r �' ri 1 r,' 'Ail A AIN NCIPAL 4 i g 1 gc. _ t, h�' "".> �_. • ... 6 I jF `.'� %� 3t p a, ��ji c.; lays �yg y., s @l 1� a g �,• % v ,,,..,_•..11:0,a- „. NH'''.. — 1 ''' i g. w .. .. � i Y k • �� ' ! :0Rik ••r'',' .'''':'''--." itt), _..:::: ere.,, K ,kr ` 0 ' t . .3+ � M_ 9^ 1" R 4. PROIM M.,".. 4 t i • i} 4*. ' . . ', 4.-.. -7.7-7,------' ••• •-I ' • t''-•, i '''•••:'•; i ' ' ' /e..... ? _ �, , ' .4 - -fir 11 ��mmnaaa 13 ! - t.:a SA_ - y4, S .A 3 •�` M .,wok • fir , . d "s,., ,, -• — ./ e i i ---A.3-i,'::,;.: ,„„,, 7 ' -''''''''' ' ' ' '''''''' . , n-i , . " r 7 i'''.it: ,',.'-',.,-.0."101....^.1411111-i;if ,9 )-,.-,.',,,Y,-* rr - ! T ! 1CA , ti .. . 1 •Lktag, 1 ^ i , s , ■ B v ' ' F .. • i " "- `„ !rz w�r4. s. .s a h" f" k`- , z� iit,,,, , li't ' ',-;:;-w,--'7.„,f,z,-,v,„0,..0.,-c..,,,,,,,,,ftts,s,„Ag-W,7t7,1%,`,.10,,,,Ms,.,:i:,1-yr,h144-7..ft ; , ^,, ,,,V; (11 ' '' ,7e 7 7-7',3Y,15,7,..,&•,.'`,,„,7'.1/4 1,...,Y7 744AVA,,i„;‘,,,,f,V.,,,,,,,:4,,,,f,/,0•, •„•,0,,,,,,i,..V,-7,,,,C474,,PZ, 74 , ' , ;'A7 ,Tr- x4 :� 4'ih�� 1-iwkAhll Fr jVs. A Ci U L)/ ' kf • (1.-, 1 YL—e.) g( 12,yn U V�-e a�ppt s 3 .. - t t a 4 � y f k _ a r'' " A, r it . The Commonwealth of Massachusetts = °- =,10 / Department of Industrial Accidents t ==11= 1 Congress Street, Suite 100 r -" MIEN Boston, MA 02114-2017 www mass gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricans/Plumbers. TO BE FILED WITH THE PERMI rrING AUTHORITY. ArspIicant Information Please Print Legibly Name (Business/Organization/Individual): r- Address: , , JO Y\J/V Cl lJtilt '•5 ? , r ,4 'api/VPhone#: QS r `f Are y an employer?Che�Ek the appropriate box: Type of project(required): 1. I am a employer with / employ-- ',.0 , or part-time).* 7. 0 New construction 10 I am a sole proprietor or partnership and hay o employees working for me in any capacity.[No workers'comp.insurance required.] 8. Remodeling 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 Demo ian 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will I O 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.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance? 13. ' ..f repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14 n Other 6 152,i 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. I'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 sum 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 employee& Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie,#: Expiration Date: Job Site Address: /e 6 4)d d 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 hereby certify under the pal and penalties of perjury than the information provided above is true and correct. Signature: 9 ,,�---� Date: � �j P/ Phone#: 7 ,2 J - 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#: