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HomeMy WebLinkAboutBLDE-22-004605 - Commonwealth of Official Use Only 4E "414 Massachusetts Permit No. BLDE-22-004605 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:2/18/2022 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) 9 WASQUE RD Owner or Tenant RESIDENT Telephone No. Owner's Address GIBBONS MELISSA A, 9 WASQUE RD, 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 e A eters New Service Amps Volts Overhead 0 Undgrd ❑�/ No.9 'M rs Number of Feeders and Ampacity `+/� �J ir5 Location and Nature of Proposed Electrical Work: Livingroom addition on rear of house. •'I ✓? ,/`) ./.,'... Completion of the following table may,6e,WitIved'lty_the 1 ctor of Wires. No.of Recessed Luminaires 12 No.of Ceil:Susp.(Paddle)Fans Noansformers • '1r" VA �t No.of Luminaire Outlets No.of Hot Tubs Generators Y < '` KVA No.of Luminaires SwimmingAbove ❑ In- ❑ 'No.of Emergen Li Pool grnd. grnd. ,Battery Units �- No.of Receptacle Outlets 14 No.of Oil Burners FIRE ALARMS No.of es No.of Switches 10 No.of Gas Burners No.of Detection and Initiatine Devices No.of Ranges No.of Air Cond. Ton l No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: 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 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: Dominic Napolitano Licensee: Dominic Napolitano . Signature LIC.NO.: 39347 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:828 GREAT FIELDS RD, BREWSTER MA 026312428 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 -l3 k2, Commonwealth o/Mamach.welb 'CZ? Use Only t —_ / cc�� cc77 Permit No. 1Z? `mot 6,0 S _�= 2 epartment o/.}ire .ervicee VI__ iOccupancy and Fee Checked BOARD OF FIRE 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 MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL IN ORMA TION) Date: .RI 17 .20 a v E City or Town of: 4 a rie To the Inspector o Wires: 0 By this application the undersigned gives notice of his or her intention to perform the electrical work described below. J Location(Street&Number) 9 W ck s V• P. R D 5 -- Owner or Tenant Gpreto ry 4 M?1 ss a._ C.7;1)430.1S Telephone No. Z Owner's Address A" Is this permit in conjunction with a building permit? Yes . No n (Check Appropriate Box) Purpose of Building {-Io•+rt___ Utility Authorization No. Existing Service-200 Amps ► tato Volts Overhead ❑ Undgrd® No.of Meters i 6 New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters kS i . Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: W'd NI 1--:J i ire o.A.M:o. Q bvl tc �cce(! c,c �f7t1. e_ Completion of the following table may he waived by the Inspector of Wires. 'V No.of Recessed Luminaires / Q No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 0 Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets /5/ No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and /D Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Municipal ❑ Other P Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: y g No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: G/000 (When required by municipal policy.) Work to Start: R/14 .20.2 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 El OTHER El (Specify:) I certify, under the pains and enalties of perjury,that the information on this application is true and complete. FIRM NAME: D ✓►xi✓►:c Nq el• -r a le`lifri- w�-- LIC.NO.: 393y 7( t4 .� -,.o Signature _D „ �• -r'�-- LIC.NO.: Licensee:D6w►,r►+c_ a (If applicable,enter "exempt"in the license nu nher line) Bus.Tel.No.: svFl'-7Y4-05 Address: S.ZEr 6v ..T —eel& O. E(et,,)etc.- Mh Da431 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 PERMIT FEE: $ Signature Telephone No. Lam. A. AIM Vvns&&sv1LrvGucb1s of 1r114JJ111..Jtuaclta ;� Department of Industrial Accidents —,1 J Office of Investigations ' �� _,Tr-_ i.� 600 Washington Street ¼;-, 11 Boston, MA 02111 wwx.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Pl.;rti%� 0 Alt 1 , ra n c) Lie e eh.G:4,/, Address: SA k- GIr'e4T- • .e(As vU) City/State/Zip: Bcew5J t"/A- dR6 31 Phone #: SO. `f a. - OS(3 Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with 4. 0 I am a general contractor and I ployees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' comp.insurance. 9. ❑ Building addition [No workers' comp.insurance required.] 5. ❑ We are a corporation and its l0 lectrical repairs or additions officers have exercised their 1 1.❑Plumbing repairs or additions 3.El I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' ❑ Other 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. tContractors 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. Lic.#: Expiration Date: Job Site Address: 9 r_(l/Q 5tV e 6 City/State/Zip: Li,c A O&L Pf4 © a‘4 It Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 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. , I do hereby certify under the pains and penalties of perjury that the information provided above ista true and correct. nature: C. 1.---)--. ... ..------ Date: //7 2—_ Phone#: .co, -—, tf 4. - c 3 G 3 Official use only. Do not write in this area,to he 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#: