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Home My WebLink AboutBLDE-22-000479 Commonwealth of Official Use Only Massachusetts Permit No. BLDE-22-000479 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:7/26/2021 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) 222 BUCK ISLAND RD UNIT 31 Owner or Tenant CORMIER RITA Telephone No. Owner's Address CORMIER KATELYN, 1 JOSSELYN PL, NEWTON HIGHLANDS, MA 02461 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check A. •r I - • i Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 Undgrd ❑ 4 j'. t> rr New Service Amps Volts Overhead 0 Undgrd 0 N•. t `�Ife Number of Feeders and Ampacity �� Location and Nature of Proposed Electrical Work: Install ductless heat pump. 1 O Completion ofthe followingtable ma) ived b t . 4,..a Wires. P I` Y No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Z3 , tiv Transformers v K 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 Initiatine Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: 1 Detection/Alertine Devices No.of Dishwashers Space/Area Heating KW Local 0 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 Siens 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 o/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 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:$50.00 C� �j/ic(/ 6119 2 f e� (tepot,,, l Ziz'./ZI cd za.460 0 Commonwealth of Massachusetts Official Use Only C` Cin-- (4 t _; II Department of,F`ire Services �:,=°_�=' Occupancy and See Checked " ..,;,.� BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/051 (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 IN'IIJKOR TYPE ALL INFORMATION) Date: 7 /Z 1 / 7 1 City or Town of: YU//Y10V 3' To the Inspector of Wires.' By this application the undersigned gives notice of his or her intention to perform the ele trical work described below, Location(Street& umber) 2- - g VG 1( 15)(44d k d Un/i- 3— ( W. Ygiiriu U 1 Owner or Tenant K 1 toi Co Mil'ey TeIephone No. '1) 5 1 ,f G G o y Ovvner'sA.ddress ' <<ia, e.. L. Ptf lydl ivori MA Ok0/ Is this p erxnit in conjunction w),h a building permit? Yes I I No (Check Appropriate Box) Purpose of Building 1\AJeli, Utility Authorization No. Existing Service Amp . / Volts Overhead I I IJndgrd n No.of Meters New Service Amps / Volts Overhead I I U'ndgrd I I No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: tv( Via SS 4' 4— kni,f f(1S)%Gt 1141-;04 . 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 Ilot Tubs • Generators KVA. No.of Luminaires Swimming Pool Above In- No.of Emergency Lighting grnd. 1 grnd. I I 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 Tota No.of Ranges No, of Air Cond. 'I'onsl No. of Alerting Devices No.of Waste Disposers Heat Pump Number Tons Z No. of Self-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Loca1I I Municnnectiipalon I I Other • Co No.of Dryers Heating Appliances KW Security'Spsterns:* No.of D No, of WaterDe-vices or Equivalent No, of No, of Heaters Signs Data Wiring: 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) VN Work to Start; Inspections to be requested in accordance with 1VlEC Rule 10,and upon completion. —sid4 INSURANCE CO'VEEA.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 ® BOND ❑ OTHER ❑ (Specify) I(iertify,under the pains and penalties of pe)jury, that the inforn7alien on this ap lication is trice and complete. I+XRM(NAIVIE; C,F, WINSLOW PLUMBING & HEATING CO„ •LIC,N0,:328'IC �-- f Licensee; RICHARD MELVIN^ "exempt„ Signature III • LIC,NO.:21529A 1 1� (Ifayplicable enter in the license number line) Bus,Tel.No,:5oe-ssq 777a Address; a REAROON CIRCLE SOUTH YARMOUTH,MA 02664 Alt.Tel.No,; N �T— *Security System Contractor License required for this work; if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally v' required by law, By my signature below,I hereby waive this I am the requirement. (check one Owner'/Agent )��owner ❑owner's agent, Signature Telephone No, I PE'RMITFEE: $ 1 E.F. Winslow Inspection Department email : inspections@efwinslow.com The Commonwealth of Massachusetts Department of IndustrialAccidents . : m. Office of Investigations =1 ~= i, Lafayette City Center —ti = r 2 Avenue de Lafayette,Boston,MA 02111-1750 o ', rots www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization 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. M I am a employer with 90 employees (full and/ 5. ❑Retail or part-time).* 6. ❑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] $ ❑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]* 11 ❑Health Care 4.Li We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 Other . • *Any applicantthat 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. X 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 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. X do hereby cer ' ie;.the ins and penalties of perjury that the information provided above is true and correct. 7 / 01/02/2021 Signature: • \, .,..,.. /G/-.,...< ,, -. 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): ,.[(Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.['Licensing Board 5.0 Selectmen's Office 6.[(Other Contact Person: Phone#: . www.lnass.gov/dia