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Home My WebLink AboutBLDE-23-005261 Commonwealth of Official Use Only L' Massachusetts Permit No. BLDE-23-005261 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked JRev.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:3/24/2023 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) 56 VALHALLA DR Owner or Tenant SCOLA SHAWN G Telephone No. Owner's Address BACHERT EMILY,56 VALHALLA DR,SOUTH YARMOUTH,MA 02664 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: Install generator 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 1 KVA 22 No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting grad. gni d. 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 Tans K\Y No.of Self-Contained Totals: Detection(Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other: Connection No.of Dryers Heating Appliances NW Security Systems:* No.of Devices or[univalent No.of Water ICW 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:$50.00 O1f.c 3/2 I2.d c 6tztrae,/8 Kw) RECEIVED `116, r ,R 2 4 2023 0 •ruvsa 0/maeeachaaafla OfficialUse Only ( in Al •t Jim nn Permit No. - 3 .5 .� l is, _ N •-rimeni of}im Jirvic� f�ING UtFARTME Occupancy and Fee Checked PREVENTION REGULATIONS 1/07] (leave blank) e�_ — [Rev. S 1 3 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(M C),5 7 C'MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: S GZ Z c L, v City or Town of: 'v �' To the Insp ctor f Wires: By this application the undersigned ives notic of his or her intention to perform the electrical work described below. CS Location(Street&Number) 7(9 node, 1.--14 eiL1—A De l\j Owner or Tenant 5GC)1-A Telephone No. %) Owner's Address t , \J A L-IA-/-„,L-z.A L} i\J Q. Is this permit in conjunction with a building permit? Yes ❑ No 4 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters c5-1-0 New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters o Number of Feeders and Ampacity .--(ZS Location and Nature of Proposed Electrical Work:C - gAkii VQ+ C-e -.1?t)`7� 2 w -ri -A146 SG311 -4 � Completion of the followingtable my be waived by the inspector of Wires. tal Trranosformers KVA lb No.of Recessed Luminaires No.of Cell:Suap.(Paddle)Fans Tf VA C KVA C1 No.of Luminaire Outlets No.of Hot Tubs Generators Above In- No.of Emergency Lighting k No.of Luminaires Swimming Pool grnd. ❑ grnd. ❑ Battery Units J No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of No.of Switches No.of Gas Burners 'No. In[tiaHngon Dete and Inli Devices ` No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained 1 Totals: Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other No.of Dryers Heating Appliances KW Securitems:* No of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications 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: 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 0 (Specify:) I certify, under the pans and pe aides f perjury,that the in rmatloaron this application f s true and complete. FIRM NA .ice/.IV-tc Al 7PJ e G LIC.NO.: 2(Z �A Licensee: l �J� KLi E Signature LIC.NO.: I CC)iL (If applicable.e r"ere ipt"in the licens number line.) Bus.Tel.No.:(5Cc�))13-7_13.1I Address: +) '"I e jt,US / - l ( �i•Wf< Alt.Tel.No.: *Per M.G.L.c. 147,s. 57-61,se ity work requires Dep ent 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)0 owner 0 owner's agent. Owner/Agent i Signature Telephone No. PERMIT FEE: $ L�c7 • The Commonwealth of Massachusetts . � I _. — Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ` 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/Individual): /� "-gtC- / O I ,C Address: b moo\ -poL,3 Okto City/State/Zip: (Aq 't ` (j2 t Phone #.15b G9 Are yo an employer?Check the appropriate box: Type of project(required): 1. I am a employer with �/ employees(full and/or part-time).* 7. 0 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself. t 9. ❑ Demolition y [No workers'comp.insurance required.] I am a homeowner and will be hiring contractors to conduct all work on my10 Building addition 4. ❑ o property. I will 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.❑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? 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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. 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: tj( 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 viol r.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifica'on. I do hereby certi under the ai s en ties of perjury that the information provided above is true and correct. Signature: -" Date: Phone#: ( S J ( 3 4� 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 b.Other _ Contact Person: Phone#: