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HomeMy WebLinkAboutBLDE-23-15928 5/24/23,6:57 AM about:blank Commonwealth of Massachusetts --ov • Y-4• Town of Yarmouth $ o , ELECTRICAL PERMIT Job Address: Cto 2 LS T6 9 LYL LLW,i.cD Unit: Owner Name: 9-7 Ct ; . c ?t Owner's Address: Phone: Email: Purpose of Building Residential Utility Authorization No.: Is this permit in conjunction with a building permit? Yes Permit Number: BLDE-23-15928 Existing Service Amps/Volts Overhead 0 Underground ❑ No.of Meters: New Service Amps/Volts Overhead 0 Underground ❑ No.of Meters: Description of Proposed Electrical Installation: Wiring for new addition. No.of Receptacle Outlets: 10 No.of Switches: 15 Generator KW Rating: Type: No. Luminaires: 2 No.of Recessed Luminaires: 20 No.Wind Generators: Wind KW Rating: No.Appliances: 3 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.0 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 0 Level 3❑ Rating: Estimated Value of Electrical Work: $ 7,500 Work to Start: May 20, 2023 FIRM NAME: License Number: Master/System and/or Journeyman Licensee: NATHAN KOWALCZYK License Number: 23363 Security System Business requires a Division of Occupational Licensure "S" LIC. License Number: Address: BLANDFORD, MA, 01008 BLANDFORD MA 01008 Email: cmleonar@icloud.com Business Telephone: 4134416258 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: Q)1/4t/ 90 4 (z3 Etft 51 C. N� 'C Cti �(-3( T 4 SQCI a�u Ck\ruf N ecC c4( ( C 1/1 about:blank _ ' '` RECEIVED t' ryy� !th o`///...1iuufts Official Use Only AY 2 3 2023 Permit No. nt af54.Seryie� Occupancy and Fee Checked DING pEPARTME a B 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 lik (PLEASE PRINT IN INK OR TYPE`/ ALL INFORMATION) Date: 5/i 9`Z3j 1 City or Town of: 7rarhlW44\ EA- 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•17 Ceett it 5�u t.ee- X(1lrfrtot)i t'arh Owner or Tenant CI1re)iopher Leonard Telephone No.(Z39) 595-6"'ilL Owner's Address in-(,st' 54%441- YrnrmnuU for} �U_�S,Upoluj Is this permit in conjunction with building permit? Yes ag No ❑ (Check Appropriate Box) V %) Purpose of Building gek, AlQA -ho to Utility Authorization No. "4 Existing Service !C C Amps /ZQ/2'fO Volts Overhead P Undg d❑ No.of Meters I New Service Amps / Volts Overhead❑ Undgrd 0 No.of Meters Number of Feeders and Ampactty l''rr Location and Nature of Proposed Electrical Work: �,it K2 u✓ 4dd1l'i0r1 Completion of the followingtable may be waived by the Inspector of Wires. (l No.of Recessed Luminaires to No.of Ceil.-Susp.(Paddle)Fans , Total I T ansformers :- KVA C KVA C) No.of Luminaire Outlets Z No.of Hot Tubs U Generators Above In- No.of Emergency Lighting t No.of Luminaires 2 Swimming pool grad 0 grad. ❑ Battery Units No.of Receptacle Outlets 10 No.of Oil Burners Q FIRE ALARMS No.of Zones Z No.of Switches 15 No.of Gas Burners �^.\\ 'No.Inof itiating Deviand ces V Initiating Devices Ili No.of Ranges 1 No.of Air Cond. Q Toms Total No.of Alerting Devices No.of Waste Disposers 0 Heat Poutamhp Number...Toes. KW 'No.of Self-Contained Detection/Alertin•Devices M No.of Dishwashers I Space/Area Heating KW 0Local❑Counnnectiicipal on ❑Other HeatingAppliances •` Kw Security Systems:* Na.of Dryers PP No.of Devices or Equivalent C No.of Water ' 'No.of //`` NNo.00fftf Data Wiring: Z� Heaters J KW Signs V No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs 0 No.of Motors © Total HP No.of Devices or Equivalent C OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work:#'.SOD•co (When required by municipal policy.) Work to Start: 5 I"o/ s 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 ® 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: n �[ UC.NO.: Licensee: 1•IA nt>.ts tSOwe.JC2y! Signature Wes'— 'III— UC.NO. VY'sli3 (If applicable. er"upt'in tn4 lleense numbr li Bus.Td.No: 1413-4 4I-648 Address: '4 1e W.11 KJ D icvd No,. 0100 8 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 0 owner's agent. Owner/Agent Telephone No. I PERMIT FEE:$ Signature The Commonwealth of Massachusetts _ Department of Industrial Accidents pla I Congress Street, Suite 100 Boston, MA 02114-2017 www.rnass.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): WA f.114.A.vt Ku in,4-A k Address: 'j' ' h pill j City/State/Zip: '3Itn1jt Phone #: 'f'Ft - 62.58 Are you an employer?Cheek the appropriate box: Type of project (required): i.❑I am a employer with employees(full and/or part-time).* 7. New construction 2.E1 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] � 3. I am a homeowner doing all work myself. t 9. [ Demolition ❑ ys [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on m YProPertY. I will 10 ® Building addition 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 5.0 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.x 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(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. lithe 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. Lic.#: 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 under the gins and penalties of perjury that the information provided above is true and correct. Signature: „ - Date: .5/l (03 Phone#: '{13 - `t`tl 67_S 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: