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Home My WebLink AboutBLDE-23-000741 0Offi-;= Commonwealth of cial Use Only 'E�, Massachusetts Permit No. BLDE-23-000741 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:8/12/2022 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) 33 CAPT DANIEL RI) Owner or Tenant BRIAN ALEXSON Telephone No. Owner's Address 33 CAPT DANIEL 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 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: Stove hood, dishwasher, &kitchen lights. 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 KVA 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 No.of Detection and Initiating Devices No.of Ranges 1 No.of Air Cond. Total n No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers 1 Space/Area Heating KW Local ❑ Municipal Connection 0 Other: No.of Dryers 1 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.pf 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 ❑ 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: Licensee: Signature LIC.NO.: (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address: 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 50Avviz, 'vN r 3/' 1-`t4 LtN (///li/'77- j gl7CZ3 : ,. RECEIVED_ ``II yy� 4` A 1 o /ur a[Ili o�///a�.+ac�iu�lte Official Use Only 3 AU6 2?O2� I ��]] \ Permit No. r127s-074 Ypf+n4At of Jir•Straka! g f LDINGDEPARTMENt Occupancy and Fee Checked 11 } •--BOARO-OP-FIREYREVENTION REGULATIONS [Rev.1/071 (b.v.bt..r) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wort to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 8'h s./2.Z CS City or Town of: Seu-rH yAz AA.aur14 To the Inspector of Wires: �J By this application the imderaigned gives notice o his or her intention to perform the electrical work described below. 2 Location(Street&Number)33 CI A Pit}t/ti D/9-Az/ L. 8014.1 O Owner or Tenant ' ,2 t es NI ,A_t_C K C ,,v Telephone No. 4.1 1—9 9 7-b(e19 Owner's Address j 3 C'e4 PTA t.'' LOA n/r e 1 /Zo/4 r S. V�1'r2 tna o u T74 MA L) Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building St Al 4 t.e—o ono r t_y l7V H+a Utility Authorization No. Existing Service 1 c>0 Amps GAP-0 Volts Overhead❑ Undgrd❑ No.of Meters I New Service Amps / Volts Overhead ElUndgrd ElNo.of Meters I Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ,Q t_Conin ,L,-/- f ! e'/- 4 v a'> --,10 S+Ot.'e/ d tS 4„,,,s 4 e e ke—PLace 41,30 k11—c,4.e,ti tk,1 t.,ts Vl Completion'lithe followingtable may be waived by the Inspector of Wires. No.of Total W No.of Recessed Luminaires No.of Ceil.Soap.(Paddle)Fans�/ Transformers KVA CINo.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- NO.of Emergency Lighting -t No.of Luminaires Swimming Pool grad. ❑ grnd. ❑ Battery Units J No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones ,C No.of Detection and No.of Switches No.of Gas Burners I Initiating Devices 1 / No.of Air Cond. Total No.of Alerting Devices 1J No.of Ranges Tons Heat Pump Number Tons,._._. KW,..„,. No.of Self-Contained No.of Waste Disposers Totals: Detection/Alertin Lo %Devices M No.of Dishwashers ( Space/Area Heating KW cal❑Connection ❑Other HeatingAppliances KW No.of Dryers L PP Security Systems:*No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW No. Ballasts No.of Devices or Equivalent Telecommunications Wiring No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: Xi,00 0 (When required by municipal policy.) Work to Start: A$At' 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 pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: Signature LIC.NO.: (If applicable.enter"exempt"in the license number line.) Bus.Tel.No: Address: 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 I ANC AIVER: I am aware that the Licensee does not have the liability insurance coverage normally required b aw. y my gnu below,I hereby waive this requirement. I am the(checkone)0 owner 0 owner's agent. Own ttre a SignattLure Telephone No.[o/7 l 4 7 GG/,J/PERMIT FEE:$ The Commonwealth of Massachusetts Department of Industrial Accidents ittir 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 PIease Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): l.❑ I am a employer with employees(full and/or part-time).* 7. ❑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. I am a homeowner doing all work myself. 9. ❑ Demolition y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on myproperty. 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. 12.0 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.] 1 •❑Roof repairs 6.E 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. 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: 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 S250.00 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 pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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 6.Other Contact Person: Phone#: