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Home My WebLink AboutBLDE-23-004636 Commonwealth of official use only ��• � Massachusetts Permit No. BLDE-23-004636 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:2/22/2023 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) 1 WEST WOODS VILLAGE Owner or Tenant BERNA SHEEHAM Telephone No. Owner's Address 1 WEST WOODS,YARMOUTH PORT, MA 02675-1462 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: Kitchen renovations 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 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: DOUGLAS S VELIE Licensee: Douglas S Velie Signature LIC.NO.: 21245 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:6 SANDY MEADOW WAY, EASTHAM MA 026426104 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: $75.00 .2-"(Z7fr3- Alr- - OCA-la CCC1 2,C(2j R IVED LWji/ ,LIC�14v(A,r2�v r 1 12 �,` y]�� FEB 2 l /�omnwnwsa[#of//(aaaac�iaaslia Official Use Only wr r, c� cc-'�� ('� Permit No. Ji ''L' BUILDING D-,� ,- 2spaPlmsniOf .}irs Jsrvics6 at By. Occupancy and Fee Checked �' .% . BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) 01 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(ME ),5 7 CMR 12.00 c•-isl (PLEASE PRINT IN INK OR TYP ,ALL INFORMATION) Date: y/19 r ` 25 City or Town of: kk, VC) To the Inspec or ,f'Wires: By this application the undersigned gi es npcie of his or her intention to perform the electrical work described below. a_ Location(Street&Num1 er) ' '\J t j'�' tot a 942 (fire .,) Owner or Tenant ar:P\ ,_K4 Telephone No. 75173 Owner's Address ] \iL 00 o) C./1�(' �-r Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead El Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters ` Number of Feeders and Ampacity `s Location and Nature of Proposed Electrical Work: r.:1 T 64 4 e1/4-4,o1/4340ri o 4 Completion of the followinktable may be waived by the Inspector of Wires. Total No.of Recessed Luminaires No.of Cell-Soap.(Paddle)Fans T of Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of l mergency 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 AlertingDevices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/AlertlngDevIces No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts 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: Z[/2 GO (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 cit verage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER 0 (Specify:) I certify,under thens,f drenal'soofperjury,that t informatio on this applicatio is true and complete. FIRM NAME: UW 6e (G1k<; itii ti. LIC.NO.: 2-i C A. Licensee: c) ✓ 1 l✓ Signature I \ , --LIC.NO.: ( Jr-02- ¶applicable,e er"xe pi-in the tie a number line. ,,y� Bus.Tel.No.: Address: Q f lkt�-1 P<C4u= kl-`„`- rAe7t141344"1 � v�4- 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 � Signature Telephone No. PERMIT FEE: $ 5 The Commonwealth of Massachusetts a Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 M_ �'� 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/Individuai): � /cr. �� ' - A l tL Address: �" �`� tuio.A.3 City/State/Zip: ' V\/ cO• L{Z Phone #: l �`'v� Z�/ - 1? el Are you an employer?Check the appropriate box: Type of project(required): l. I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E Building addition 4.E 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.E Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E Other 152,§I(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box 41 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: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: 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 certify er the pa s i n s1,ena ties perjury that the information provided above is true and correct.[2-62-- Signature: Date: 0 Phone#: 4 T _ (✓ tel P 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#: