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Home My WebLink AboutBLDE-22-001326 ''I'‘ Official Use Onl rV Commonwealth of y s, 12!ty 1} Permit No. BLDE 22 001326 Massachusetts 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:9/7/2021 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) 47 SISTERS CIR Owner or Tenant Bassi! 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: Wiring for pool. Completion of the following table'nay 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. Tonal No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting 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 Signs 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: ANDREW M LEVESQUE Licensee: Andrew M Levesque Signature LIC.NO.: 17318 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:461 LOWER COUNTY RD, HARWICH PORT MA 026461831 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: $85.00 4 klan e,GAi2. N o -- -`( 447_4 V i 7/ / 2/ / P4-17 0 Gi2,75-mill, et/24,4 le: - .6 /1/41F-4t--- 144(2-3 Ve----- . IR ® ! !w 1 Commonwealth o/ff laddaclzudettd Official Use Only W . N 12 ' ç ccyy�� {{�� Permit No. 22--— (3 i = '.'� 9 !y I -Apartment of 3ire Serviced . ` Occupancy and Fee Checked O ,� I' BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) 0 i a- Z 1 APPLICATION FORPERMIT TOPERFORM ELECTRICAL WORK 1 Cl)W 15 11 All work to be performed in accordance with the Massachusetts Electrical Xad 527 CMR 12.00 LU �i n 0'LEASE PRINT IN INK OR T PE ALL INFORMATION Date: ) 1e CO on City or Town of: w-m-r To the Inspect r of Wires: By this application the undersign 'yes notice� o'fs his r her intention to perform the electrical work described below. f Y 4' Location(Street&Number) IC Owner or Tenant L Telephone No. Owner's Address Is this permit in conjunction with a buildinpermuit? Yes No I—I (Check Appropriate Box) Purpose of Building /{ t� N W Utility Authorization No. Existing Service �-F/Y/ Amps 1/-t/ /2-6Volts Overhead Undgrd 0 No.of Meters I New Service Amps / Volts Overhead U Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: I�I I1�, riX1\ir[ ki & (i 1- (Iv'&•�,ND C i 1 t & L- Cor pletion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:SusP•(Paddle FansT of TV) Tr.aTransformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires SwimmingPool Above ❑ In- ❑ No.of Emergency Lighting grad, grad. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detectionand Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Self-Contained No.of Waste Disposers HeaTott als:mp Number Tons KW Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Municipal ❑ Other P I Connection No.of D ers Heating Appliances KW Security Systems:* 1 y No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent cations Wiring: No.Hydromassage Bathtubs No.of Motors Total HP Te1ecommuni No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 54/01' — (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"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 IN BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Harwich Port Heating& Cooling, LLC LIC.No.:17318A Licensee: Andrew Levesque Signature ,v/ LIC.No.:35976E (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:508-432-3959 Address: 461 Lower County Rd, Harwich Port, MA O2o4o Alt.Tel.No.: *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. ** Please fax a copy back to us at 508-%' =' -6075 ** or e-mail to: keciaRhphcllc.com The Commonwealth of Massachusetts Department of Industrial Accidents '.. Office of Investigations j i ? 600 Washington Street oston,MA 02111 www.inass.gov/aia Workers' Compensatio i Ins ranee Affidavit: : uilders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Harwich Port Heating&Cooling LLC Address: 461 Lower County Road City/State/Zip: Harwich Port MA 02646 Phone#: 508-432-3959 Are you an employer?Check the appropriate box: Type of project(required): 1.Gzi I am a employer with 65 4. I am a general contractor and I 6. 2 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. 2 Remodeling shipand have no employees These sub-contractors have g ❑Demolition working for me in any capacity. employees and have workers' 9. [ Building addition [No workers'comp.insurance comp.insurance.t required.] 5. ❑ We are a corporation and its 10.12 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.2 Plumbing repairs or additions 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' 13.12 Other HVAC 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' ers'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: Selective Insurance Company of South Carolina Policy#or Self-ins.Lie.#: WC9059813 Expiration Date: 10/26/2021 Job Site Address: I S--f ?5 ('4" V 7VL/ City/State/Zip: 1/I tI 1 Attach a copy of the workers'compensation policy declaration page(showing the policy nu ber 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 t to 'tand petfuilties of peljury that the information provided above is rue and correct. /f,+ Signature: Date: �� /1 l Phone#: 508-432-3959 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#: b'