HomeMy WebLinkAboutBLDE-23-003084 Commonwealth of Official Use Only 4, l I Massachusetts Permit No. BLDE-23-003084 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:12/6/2022 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. Location(Street&Number) 61 COMMONWEALTH AVE Owner or Tenant NAUSET DISPOSAL Telephone No. 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. 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 general office area and remove FPE panels 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 Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alertine Devices No.of Dishwashers Space/Area Heating KW Local 0 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: TYLER W PAYNE Licensee: Tyler W Payne Signature LIC.NO.: 22091 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:5 JANS PATH, HARWICH MA 026452458 *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt.Tel.No.: 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:$320.00 Qr43,162.12/4 I �` 'tZv ,.. i / vv e iae c/_ CAI Glib 1 s'ict pi L1 Siez3 Cc dam— 7r?/- ACriturrosumeaki 4 Maarschatroilei official use only ' a" *+arbrrw#'f .. andeed Permit No. .3—3 BOARD OF FIRE PREVENTION REGULATIONS Occupancy en(le Fee eA ave Murk) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(M ,527 CMR 12.00 (PLEASE PRINT IN INK OR TTP ALL ORMATION) Date: /�/$ fir" City or'Town of GV'f+V y j To the Inspector of Wires: By this application the ,.,,.-,,.;, Odes noticeof his or her intention to the work a ribedbelow. Location(Street&Number) f% G1/1'1 m " l 41 Owner or Tenant N4()St-i- "DI O CA Telephone No. Owner's Address 3 tA) q.('e✓tt4 ' f/ £ik lI ' IX 7761s h ibisft in ausionielify with a , Yes No 0 (Cl A roprish Box) w Purpose of Bo •'6 til I Utility Authorteedon No. , Existing Service Amps /Z ' I Volts Overhead' Undgrd El No.of Meters I New Service Amps / Volts Overhead❑ Undgrd[l No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ,L V44 .07,1e l din A A i'�'4 - Y( ►ad€/ --z>/-7,en C millet on of the f flow 70 be waived by the Innsonor of W res. rota tb No.of Recessed Luminaires No.of Cell.-Snap.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Na.ofLsol itaairas Swlmmin Pool Above In- Ira ormerpetaey t trttng j arod. ❑ Arad. Ilttits t Outlets No.of OS Burners ALARMSv No.of Zeus 't No.ofSwits No.of Gas Burners o and Initiating r 6 No.of Ranges No.of Air Cond. Toon l No.of Alerting Devices No.of Waste osers. 'RentP p Number Toes KW a of Sal Contai d No.of l rtwns Space/Area Heating KW Load ondo ( tioig 0 odor No. —Heaths Appliances Kw t• No.of or Eseirdent No.of Water K, No.of No.ofWiring: HeatersSigns Ballasts No.of Devices or ' , : t No. ) No.of Motors Total HP Tale mmunicadons ' ' i:, • No.of Devices or Fart ::,t OTC: ,�i, Attach additional detail4'+des1ra4 or as rep by the for of Wires. EstimatedValue of • Work: Jv ,k (When required by municipal policy.) Work to Start c, z Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C 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 ce is in force,and has exhibited proof of same to the permit office. CHECK ONE: INSURANCE� �ND 0 OTHER 0 (Specify;) Icy;Nader thejosins end .. , t the i raradon en is*rue end comitiete FIRM NAME: ',at/A, 4' �/7( 7 LIC.NO.: Z Licensee: 1Z . signaar Y� LIC.NO.:Z2o�l 4 (If .,apt"in mba,r line) g t9�`�ii� �l(�i'G/ Bus.Tel.No.. 2 Address: T.0 trio O 21a4 *Per M A L,.c. 147,s.57.61,security work/ AIt.TeLLie. N No..•i7_:.= ',,, , OWNER'S INSURANCE W' ���of Public Say"S"License: Lie. �'I a'. � � WAIVER: I am aware that the Licensee does not have the liability insurance coveragely required by . By my signature below,I hereby waive this requitement. I am the(check Dire©owner d ma's gent. Signature Telephone No. I PER IIT FEE:$ I . The Commonwealth of Massachusetts ` ' -• ► _�_, _fi Department of Industrial Accidents k =ia41l_ 1 Congress Street, Suite 100 ''. Boston, MA 02114-2017 .alwww mass.gov/dia `� Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information '�,� I . Please Print Legibly Name (Business/Organization/Individual): < I b..ti y`-C. �GLL '(Yl u.( /�G Address: IP' 0 • 1aoX 0 ���/// City/State/Zip: S•S. )D1'l. -h d2(i�i Phone#: �Ni2G61- 3. i , Are you an employer?Check the ppropriate box: Type of project(required): 1. am a employer with employees(full and/or part-time).* 7. ❑New construction ? I am a sole proprietor or partnership and have no employees working for me in 8. 's,' emodeling any capacity.[No workers'comp.insurance required.] 9. • Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 10 ❑ Building addition . 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.Ei Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§I(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. t� j Insurance Company Name: kJ /4 h I o Li A/ Wee 'l Policy#or Self-ins.Lic.#: V" ee—�V—50 i(-N ik, Expiration Date: -5/ i 1 kZ, Job Site Address: 61 ( P1P/tOf t€4 iitiéOA,c4l City/State/Zip: itAk 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 o ' tatement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c ' e p ' and penalties of perjury that the information provided above is true and correct Signature: Date: ,2/5/ Z i- Phone#: -77 /2O'1' 5/t& Ceti -77(-(, Pi - 301 Z. 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#: