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Home My WebLink AboutBLDE-23-002767 Commonwealth of Official use only n\iv-) Massachusetts Permit No. BLDE-23-002767 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:11/17/2022 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, p n(fir t Location(Street&Number) 920 GREAT ISLAND RD Li/(ri" -1' 1-1- 0 1.` Owner or Tenant ANDREA MIHOS 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: Installation of life safety system Completion of the following table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(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 FIRE ALARMS No.of Zones No.of Detection and 12 No.of Gas Burners No.of Switches Initiating Devices No.of Air Cond. Total No.of Alerting Devices No.of Ranges Tons Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices Space/Area HeatingKW Local 0 Municipal 0 Other: No.of Dishwashers P Connection HeatingAppliances KW Security Systems:* 4 No.of Dryers PP No.of Devices or Equivalent No.of Water KW No.of No.of Ballasts Data Wiring: Heaters Signs No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. required Value of Electrical Work: (When q uired by municipal policy.) y') 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: Gene A Cormier Licensee: Gene A Cormier Signature LIC.NO.: 1592 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:9 MARGATE LN, SOUTH DENNIS MA 026602667 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. I PERMIT FEE: $50.00 I (\/) tei-- (t 22 - (i — '-' L"/I) Ck(xi t'i 11-Ir l-it i Commonwealth.o////�//qadeachu// ie Official Use Only C Permit No. '��7 i =: 1 c c� _� eLJepartment ol ire Seruiced 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(MEC),527 CMR 12.00 H (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: November 11, 2021 5 City or Town of: Yarmouth To the Inspector of Wires: c4 By this application the undersigned gives notice of his or her intention to perform the electrical work described below. a. Location(Street&Number)920 Great Island Road Owner or Tenant Andrea Mihos Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes p No 11 (Check Appropriate Box) Purpose of Building RESIDENTIAL Utility Authorization No. Existing Service Amps / Volts Overhead n Undgrd n No.of Meters New Service Amps / Volts Overhead 1 1 Undgrd 1 I No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install new life safety system in existing home a new room Please FAX Permit& Permit# back-508-398-5666 or EMAIL - sales@capecodalarm.com Thank You Completion of the following table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(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 FIRE ALARMS INo.of Zones No.of Detection and 12 No.of Switches No.of Gas Burners Initiating Devices Total No.of Alerting Devices CANo.of Ranges No.of Air Cond. Tons Heat Pump I Number i Tons I KW No.of Self-Contained UO No.of Waste Disposers Totals: Detection/Alerting Devices Municipal LI Other —J No.of Dishwashers Space/Area Heating KW Local❑ Connection Security Systems:* 4 No.of Dryers Heating Appliances KW No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters Signs KW Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work:$3795.00 (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"completa.bperation"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:) Li.) I certify,under the pains andpenalties lties of perjury,that the information on this application is true and complete. IC.NO.: 1592C 3 FIRM NAME: Cape Cod Alarm Co., Inc. Signature ! NO.: p Licensee: GENE CORNIER Si g Bus.Tel.No.:508 398- 316 (If applicable, enter "exempt"in the license number line.) Alt.Tel.No.:800 468-8300 Address: 204 OLD TOWNHOUSE ROAD WEST YARMOUTH, MA 026736 *Per M.G.L.c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. SS CO 000248 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 Ogent. I Owner/Agent Telephone No. I PERMIT FEE: $ Signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): CAPE COD ALARM CO., INC. Address: 204 OLD TOWNHOUSE ROAD City/State/Zip:WEST YARMOUTH, MA 02673 Phone#: (508) 398-6316 Are you an employer?Check the appropriate box: Type of project(required): 1. ✓❑ I am a employer with 30 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub contractors 6. El 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 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ officers have exercised their I am a homeowner doing all work 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] ' c. 152, §1(4),and we have no 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 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. Insurance Company Name: Associated Employers Ins., Co. Policy#or Self-ins. Lic.#: WCC-500-5006433-2022A Expiration Date: September 1, 2023 Job Site Address:920 Great Island Road City/State/Zip:East Yarmouth Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL 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 certify under the pains and penalties o perjury that the information provided above is true and correct. Signature: �/{ eta", Date: November 11, 2021 Phone#: (508) 398-6316 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#: