BLDE-21-006892 Commonwealth of Official Use Only
it_.:_.01,.. :4\
Massachusetts Permit No. BLDE-21-006892
� 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:5/27/2021
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) 22 HARBOR RD
Owner or Tenant VANDERLINDEN MARY V Telephone No.
Owner's Address KEANE J M &M E, 3 DOROTHY AVE,WORCESTER, MA 01606-2209
Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Approp 'ate Box)
Purpose of Building Utility Authorization No. Q //
Existing Service Amps Volts Overhead 0 Undgrd 0 /,-N e
New Service Amps Volts Overhead 0 Undgrd 0
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Replacement HVAC. 0
Completion o the followingtable maybe wi , c , .. Wires.
P .l� �i' J
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of
klii4x
Transformers
No.of Luminaire Outlets No.of Hot Tubs Generators fiff
No.of Luminaires Swimming Pool Above ❑ In- ElNo.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 1 No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. 1 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 ❑ Other:
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: (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: E F WINSLOW PLUMBING HEATING CO INC
Licensee: RICH M MELVIN Signature LIC.NO.: 21829
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address:8 REARDON CIRCLE, SOUTH YARMOUTH MA 02664 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
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: $50.00
Commonwealth of Massachusetts Official Use Only
_-l ( A- 7 M � Z�=��i,__ Permit No.
_,.a,,_ Department of Fire Services
iF Occupancy and Fee Checked
�' BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/051
"'1):.�., (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT DT INK OR TYPE ALL INFORMATION Date: 500 /Z I
City or Town of: YgiNIW 4-14 To the Inspector of Wires:
By this application the undersigned gives notice of or hi Sher intention to perform the -
electrical work described below,
Location(Street&Number) a ). llc,fbaf k j W 4 Yodiim,tj4., U Z 4
Owner or Tenant b l Cl�-, t i/Nn Oer- L_;✓- f C P.' Telephone No. '0 6 q l 10 7/1
Owner's Address 1-1,(1 Sdt6/1 6*. 01/4do 1 i ci .e MA OA$b
Is this permit in conjunction with a building permit?d Yes n NoCheck Appropriate Box)
Purpose of Building 0 u4kVAIP Utility Authorization No.
Existing Service Amps / Volts Overhead n Undgrd n No.of Meters
New Service Amps / Volts Overhead n Undgrd n No.of Meters
•
Number of Feeders and Aanpacity
Location and Nature of Proposed Electrical Work: I1M1OLD. t 1\,C iv'5M11d ON
•
Completion of the followin, table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers VA
No.of Luminaire Outlets No.of Hot Tubs • Generators IKVA
Above In- No.of Einergency Lighting
No.of Luminaires Swimming Pool grad. n grnd. II 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
Heat Pump Number Tons KW No.of Self-Contained
No.of Waste Disposers Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating IOW Local I Municipal l I Other
Connection
No.of Dryers Heating Appliances KW LSecurity'Systerns:*
No.of Devices or Equivalent
No.of Water I£ 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: (When required by munioipal 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
O undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ® BOND ❑ OTHER 0 (Specify:)
I certify,under the pains and penalties of pedury,that the information on this ap lication is true and complete.
FI,RIYI NAME; F.F. WINSLOW PLUMBING & HEATING CO., I .LIC,NO.:3281 C
Licensee: RICHARD MELVIN Signature • LIC.NO.:21829A
(If applicable, enter"exempt"in the license number line.) Bps.Tel.No,:508-394.7778
0 S Address; B REARDON CIRCLE SOUTH YARMOUTH,MA 02864 Alt.Tel.No.:
Lo *Security System Contractor License required for this work; if applicable,enter the license number here:
LD 0-5 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
ks) required by law. By my signature below,I hereby waive this requirement. I am the(check one)Downer n owner's agent,
Owner/Agent
M. Signature Telephone No. PERMIT FEE: $
F.F. Winslow Inspection Department email : inspections@efwinslow.com
The Commonwealth of Massachusetts
b_ Department of IndustrialAccidents
Enl Office of Investigations
A _ Lafayette City Center
1/47,—= o. 2 Avenue de Lafayette,Boston,MA 02111-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organi7ation Name: E.F. WINSLOW PLUMBING & HEATING CO, INC.
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778
Are you an employer? Check the appropriate box: Business Type(required):
1.0 I am a employer with 90 employees (full and/ 5. U Retail
- ~ -part-time).* 6. jl Restaurant/Bar/Eating Establishment -
2.❑ I am a sole proprietor or partnership and have no 7. [ Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp. insurance required]** 1 LEI Health Care
4.U We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.0 Other . •
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
.i am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:
City/State/Zip:
Policy#or Self ins. Lic.#1964A Expiration Date:01/01/2022
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under§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 uT 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 cer ' �e.the, xins and penalties of perjury that the information provided above is true and correct.
G 01/02/2021
? "* -Signature: Date:
Phone#: 508-394-7778
Official use only. Do not write in this area,to be completed by city or town official. •
City or Town: Permit/License#
Issuing Authority(check one):
1.0 Board of Health 2.0 Building Department 3.[)City/Town Cleric 4.❑Licensing Board
51 Selectmen's Office 6.[]Other
Contact Person: Phone#: •
www.mass.gov/dia