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Home My WebLink AboutBLDE-21-001120 Commonwealth of Official use only € . k I Massachusetts Permit No. BLDE-21-001120 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) City or Town of: YARMOUTH Date: /2/2020 By this application the undersigned gives notice of his or her intention to perform the electrical work described below.r of Wires: Location(Street&Number) 47 SISTERS CIR Owner or Tenant ROBERTSON DOUGLAS A TRS Owner's Address RYER JANE E TRS, 868 WATERTOWN ST, W NEWTON, MA 02465 Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Purpose of BuildingAppropriate Box) t7g it`�"(_ ,6 Existing Service Amps Utility Authorization No. 6{7 0 f 3.i V n g°�1 "' p Volts Overhead 0 Undgrd 0 No.of Meters "' New Service 200 Amps Volts Number of Feeders and Ampacity Overhead 0 Undgrd 0 No.of Meters Location and Nature of Proposed Electrical Work: New residence. 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 Transformers Total KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires SwimmingPool Above In- grnd. ❑ grnd. ❑ No.of Emergency Lighting No.of Receptacle Outlets Battery Units No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges Initiating Devices No.of Air Cond. Total Tons No.of Alerting Devices Heat Pump I Number I Tons Totals: KW No.of Self-Contained No.of Waste Disposers No.of Dishwashers Detection/Alerting Devices Space/Area Heating KW Local 0 Municipal Connection ❑ Other: No.of Dryers HeatingAppliances pp KW Security Systems:* No.of Water KW No.of No.of Devices or Equivalent Heaters No. No.of Data Wiring: SigBallasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent Estimated Value of Electrical Work: Attach additional detail if desired,or as required by the Inspector of Wires. Work to start: (When required by municipal policy.) 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 ❑ :) Icertify,under the pains and penalties o y, er'ur that the information on this application istrue and complete. FIRM NAME: ANDREW M LEVESQUE Licensee: Andrew M Levesque Signature LIC.NO.: 17318 (If applicable,eater"exempt"in the license number line.) Address:461 LOWER COUNTY RD, HARWICH PORT MA 026461831 Bus.Tel.No.: Alt.Tel.No.: *Per M.G.L.M.G.L.C. 147,s.57-61,security work requires Department of Public Safety 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 Owner/Agent one) 0 owner 0 owner's agent. Signature /ty/ ,ems Telephone No. 1�,� ( PERMIT FEE: $180.00 n-- V �}?T S/{0�7� kg_„ 3 `-Cr111l3 7)2" ..e 6re,i C'JS Foil. 9 (i j (Pp ia ' )(gip z"-1' rocC m cj 'iJl& 01 p`' c. Oi G 1>>bi (7i 4It51�/ Q� J C L ey N fr Ai/Gilts-0 G/sizl 6 TW 4- t 0.,,,,' UGC 344! h /� CommonWealth o/714 3achVett3 Official Use Only ' � __ ' 1- icy -�_�_ C� Permit No. (�' L.t � �ePartment o��'re�Jeruice3 �"� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/(l7J (leave blank) APPLiCCATION FOR PERMIT 1( TO PERFORM ELECT RUCAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C,5 (PLEASE PRINTININK OR TYPE AL L`VF0RIYL4TIONJ Date: (,?, .3 j /27 CMR I2.00 City or'Tuwss of: /F n F� g�"i-f To the Ins/ector df By this application the undersigned ves notice ofhis or her intention to perform the electrical work Wires: below. Location(Street&Number) + e ss EK G K C r E yAxttiourtfifrectir Owner or Tenant S CjLI Vlr Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes W No oN Purpose of Building �u t>G 1 J ❑ t0 Appropriate]Sox) UtfllityAaathorizatjoaa No. Existing Service Amps / Volts Overhead �M El IITndgrd' I No.of Meters New Service Amps I2�/2 Volts Overhead i l ❑ Undgrd P No.of Meters Number of]E+eeders and Ampacity Location and Nature of Proposed Electrical Work: WI i I v& or Nftiv S t^ b z Completion ofthe following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.ofCeiL-Susp.(Paddle)Fans No.of Total No.ofLuaniaaaire Outlets Transformers KVA No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above j- No.ofEmer Emergency Lightmg g grad. ❑ grnd. Battery Units y g g No.of Receptacle Outlets No.of Oil Burners . . _. FIRE ALARMS INo.of Zones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges Total Initiating Devices No.of Air Cond. Tons No.of Alerting Devices HeatPum No.of Waste Disposers l? Number Tons KW No.of Self-Contained 'Totals:I Detection/Alerling Devices No,of Dishwashers Space/Area Heating KW Local❑Municip Connectialon 0 Other No.of Dryers Heating Appliances KW Security Systems;* No.of Water KWNo.of No. vices orE i I' alent Heaters N°'ofData Wiring: Si.g s Ballasts No.of Devices or E I uivalent No.]l3ydromassageBathtubs No.of Motors Telecommunications Wiring: Total HP No.of Devices or E 1 arivalent OTHER: Estimated ValueofElectricalWork: '� � Attach additional&iaizfdesiredorasregafredby the Inspector ofWires. Work to Start- � a ,Z( (} (When required by municipal policy.) Inspections to be requested in accordance with MBC Rule 10,and upon completion. 1NSUI&ANCE CO 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 IN BOND [] OAR Ej Sec I certify,under thepains and penalties o (P afy:} P fperjury,that their formation on this application is true and complete. IIRMNAME:Harwich Port Heatin &Coolin , LLC me.NO.:9 7316A Licensee:Andrew Levesque a applicable, Signature err' LIC.NO,359761✓ ((Ifpp 'cable,enter"exempt"in the license number line.) Address: 461 Lower County Rd Harwich Port MA 02040 • Bus.Tel.Nn.:508 43_ *PerM.G.L c.147,s 57 fit,security work requiresAlt:Tel.No.: fl WNBR'S INS Department of Public Safety"S' License: Lie.No. URANCE' 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 0 owner's a•ent. Owner/Agent Signature Telephone No. PERMIT FEE: ** Please fax a copy back to us at 508-430:6075 ** or e-mail to: keciaghhcllc com 1122� 1i t. The Commonwealth of Massachusetts a� Department of Industrial Accidents 7!} .. . r Office of Investigations . -: -' 600 Washington Street ` r Gaston,MA 02T1 YY- -i www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/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.M I am a employer.with 75 4. L] I am a general contractor and I 6. I v New construction employees(full and/or part-time).* have hired the sub contractors 2.I II am a sole proprietor or partner- listed on the attached sheet. 7. Ivj Remodeling ship and have no employees• These sub-contractors have 8. n Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp.insurance comp.insurance.t required.] 5. n We are a corporation and its 10.p Electrical repairs or additions 3.n 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 q ] employees.[No workers' 13.p 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'comp.policy number. I am an employer that is providing worker's'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.Lic.#: WC9059813 Expiration Date:)1.M0J14O 10/26/2020 Job Site Address: t SI c-rE K C ` IZ City/State/Zip: V1i3( T 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 pain et and penalties ofperjury that the information provided above is true and correct. Signature: - �vwl Date: 3 1 /zO , I 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#: