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Home My WebLink AboutBLDE-23-15974 6/2/23,5:56 AM about:blank Commonwealth of Massachusetts ov . YAt, M Town of Yarmouth ELECTRICAL PERMIT , Job Address: 24 NANTUCKET AVE Unit: Owner Name: ANDERSON HOLLIS BETH Owner's Address: 24 NANTUCKET AVE Phone: Email: Purpose of Building Residential Utility Authorization No.: 12541849 Is this permit in conjunction with a building permit? No Permit Number: BLDE-23-15974 Existing Service Amps 0/Volts Overhead IN Underground❑ No.of Meters: New Service Amps 200/Volts Overhead MI Underground 0 No. of Meters: Description of Proposed Electrical Installation: Upgrade service No.of Receptacle Outlets: No.of Switches: Generator KW Rating: Type: No. Luminaires: No.of Recessed Luminaires: No.Wind Generators: Wind KW Rating: No.Appliances: KW: No.Water Heaters: KW: No.Transformers: Total KVA: Space Heating KW: Heating Equipment KW: No.Motors: Total HP: Total KW: No. Heat Pumps: Total KW: Total Tons: Fire Alarm System❑ No.of Devices: Swimming Pool: In-Grnd.❑ Above-Grnd.❑ Hot Tub❑ No.of Self-Contained Detection/Alerting Devices: No.Oil Burners: No.Gas Burners: Video System ❑ No.of Devices: No.Air Conditioners: Total Tons: Telecom System ❑ No.of Outlets: No. Energy Storage Systems: KWH Storage Rating: Security System ❑ No.of Devices: Solar PV KW DC Rating: Solar PV KW AC Rating: No.of Electric Vehicle Supply Equipment: No.of Modules: Roof-Mount❑ Ground-Mount 0 Level 1 ❑ Level 2❑ Level 3❑ Rating: Estimated Value of Electrical Work: $ 1 Work to Start: May 23, 2023 FIRM NAME: License Number: Master/System and/or Journeyman Licensee: BRETT A DUGUAY License Number: 22079 Security System Business requires a Division of Occupational Licensure "S" LIC. License Number: Address: MIDDLEBORO, MA, 023463065 MIDDLEBORO MA 023463065 Fee Paid: $50.00 Email: brettd@bdelectricalservices.com Business Telephone: 508-617-0800 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. INSURANCE: "/ ,'- (z3 (Hi- J MA IA74-' p62_ Vl5T/a"r C 1!N e"/2-4Wre ') ill about:blank :: RECEIVED Official Use Only A rJUN U Co nWQa o/ a. act 7 23 -1S ,� i ;, l: - �J �`7 Permit No. T ^ 'h _-.-_._ Of Jill JBPVKBd 4 j BUILDING DE FYAHKR Occupancy and Fee Checked . '' �4 `BOARD OF FfRE PRE NTION REGULATIONS [Rev. 1/07] (leave blank) 2 IAPPLICATION 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)City or Town of: `\ Date: t�(1(i1 4bcj+ `C�Y ilk\�� h To the Inspector of Wires: By this application the undersigned gives notice of his or her intention Owner or Tenant ,j l 'S.\c. o , �, Telephone No. C Owner's Address , `A \IcirYb i( V 0 ak- bu-k-Y1 ci (° A -. ,, ,-,,a- o a 1 v l D� Is this permit in conjunction with a building permit? Yes [ No ❑ (Check Appropriate Box) �Cl t i Purpose of Building ' . h.�l At Utility Authorization No. \'S L\\ u 0\ � Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps 0,0 / Volts Overhead EX Undgrd❑ No.of Meters d Number of Feeders and Ampacity r\j r, Location and Nature of Proposed Electrical Work: �J- \ :(U1( ),0(-) rivyvp 1A cry-ctua_ se V) Completion of the followin&table may be waived by the Inspector of Wires. vt No.of "total INo.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA CI No.of Luminaire Outlets No.of Hot Tubs Generators KVA it Above In- No.of Emergency Lighting No.of Luminaires Swimming Pool grad. ❑ grad. ❑ Battery Units J 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 11,,,i No.of Ranges No.of Air Cond. Tonsl No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained sp Totals: Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Municipal ❑ Other p Connection No.of DryersHeating Appliances KW LSecurity Systems:* No.of Devices or Equivalent No.of Water , No.of No.ofIC' Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.A dromass a Bathtubs No.of Motors Total HP T°I No of Devices ora y�Equivalent y ag No.of lleviees or Equivainnlent 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: !', 1)Api Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERA ,'GE: 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 ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: ( r�M(• (QX ?f' '>t (Sl SC o r (✓l (, LIC.NO.: 1 d.b a 7�,, Licensee: I )r e-'-A c`l('1�LA(1( Signature lisal LIC.NO.: C(If applicable,enter"exemt?in t license nu�"�'line.) ( Bus.Tel.No. r c 0 Address: ) r rilf,V( \ i(1,y l'CI f 1 MA 0�)O Alt.Tel.No.: r 1,2),_v *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 PERMIT FEE: $ �� Signature Telephone No. • The Commonwealth of Massachusetts 1, 1 Department oflndustrialAccidents 1 Congress Street, Suite 100 \' ,,/,1 Boston, MA 02114-2017 tir ` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): bi) C�i;Lc r1l cc, !N if s uc, --) i L i Address: VY l'11^� yv VOL `�(\(Ct, 1 City/State/Zipt j' )C1, M (.4, Phone #: % (Pl. • 0%00 Are yop an employer?Check the appropriate box: (;u7(/ Type of project(required): 1. I am a employer with 't C' employees(full and/or part-time).* 7. _ New construction 2.❑I am a sole proprietor or pa,w*:ership and have no employees working for me in 8. ❑ g Remodelin any capacity.[No workers'comp. insurance required.] — � 3. I am a homeowner doing all work myself. t 9. _ Demolition ❑ y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hirin contractors to conduct all work on m roe 10 n Building addition g YP property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.$ 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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. Insurance Company Name: A k rVI IhSkrov ;A _si.-)C,caks 1_ I (. Policy#or Self-ins.Lie.#: ANC i C_?)Lj Lit)3(0g(),J.,3,A Expiration Date: Lk \`3 \ do:4,Lk Job Site Address: al-\ mr\,k,( li 0 Av(. City/State/Zip:SD aV\1r 1rm+m-A-t1,rWos b9(49L 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 c ertify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 1 ,,,,��. Date: 1IVAI. '0`,19) Phone#: 0 ) 'I)t' ''''') `'-) C:3 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#: