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HomeMy WebLinkAboutBLDE-23-0005219 Commonwealth of Official Use Only "' ►i` Massachusetts Permit No. BLDE-23-000519 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:8/2/2022 City or Town of: YARMOUTH To the Inspector of Wires: By this application the undersigned gives notice of his or her mtentron to perform the electrical work described below. Location(Street&Number) 186 CRANBERRY LN Owner or Tenant JOHN ALBERICO Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ 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: Family room,garage,basement playroom,kitchen,&foyer. 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- ❑ 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 Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Na.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting 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 Sinus 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:) c J7 _449�1Q — I terrify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Jack W Griffin Licensee: Jack W Griffin Signature LIC.NO.: 418 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:26 JOANNA DR,S YARMOUTH MA 026641339 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:$150.00 COTE LAC 07We r►'.c zt g124.672 . 9,0,0441 C4PM ea.#ro9sucy Q49 4/42.240 (3/23 jRECEIVED will C_cA.-LtZ [ C. mmonwealth of Massachusetts Official Use Only AUG'=_ 0 epartment of Fires Services Perm,t No.�Z S—0-C1 9 �— ' Occupancy and Fee Checked BUILL':NG =4J' A'D OF FIRE PREVENTION REGULATIONS By __- (Rev.9/05) (leave blank) . APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK LO All work to be performed in accordance with the Massachusetts Electrical Code(M ',527 CMR 12.00 2 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) /f Date: F I c . _ City or Town of: Cent I To the Inv a of Wires: By this application the undersigned gives notice his of her intention to/perform the electrical work described below: Location(Street&Nu ) /( C 4n1 fjj—hie � _` N _ . — Owner or Tenant /,..) /t�h e 1C7 t� �_ __ Telephone No. Owner's Address 1/4P4 r'`-�... Is this permit in conjunction a,building permit? Yes No ❑ (Check Appropriate Box) oPurpose of Buildin . / ►Q. 11, _1'j_PO i..P . Utility Authorization No. v Existing Ser�vicei�'° Amps lO/c) /C Volts Overhead❑ Undgrd No.of Meters / New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity t v Location and Nat of Pr posed Electrical Work: r�r I hi f2r�d >+ g �t2 Completion of the following Cable may be waived hf the Inspector of Wires. No.of Recessed Luminaires No./74561A-of Ceil.-Soap.(Paddle)Fans Transformers Total No.of Luminaire Outlets No.of Hot`MS Generators KVA "`Li No.of Luminaires Swimming Pool monde ❑ grad. ❑ BatteryUni s cy Lighting ...1.. 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 Dis Heat Pump Number Tons KW No.of Self-Contained Piers Totals: Detection/Alerting Devices V No.of Dishwashers Space/Area Heating KW Local❑Municipal =Other Connection Vi No.of Dryers•ers Heating Appliances KW Security yystems:' No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent c.----7 No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications de Wiring: OTHER: Attached additional detail if desired.or as required by the Inspector of Wires. Estimated Value Ele .cal Work: (When required by municipal policy.) Work to Start: i Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE OV RAGE:Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liabilit•�insurance including"completed operation"coverage or its substantial equivalent.The undersigned certifies that such cov ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND❑ OTFIF,R❑ (Specify:) I certify,under the pains and penalties of p,(:dpry,that the information on this application is true and complete. /4fie;/ J� FIRM NAME: Jn-c(! ft-{t i(/v LIC. NO.: 9/9 �r((� Licensee:��C //'' G rf- -�/� Signature LIC. NO.: a�c— 7 // I (If applicable to 'in the license number line.) t� _ �,}�� Bus.Tel.No.: Q -ce2 Q—off.ra / Address: c" 2 )/ it ✓mp ""�'7 Alt.'fel.No.: "Security System Contractor License required for this wot) if applica e.enter the license number here: 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 Signature _ Telephone No. _ PERMIT FEE:$ /,O ,0() 7I VI 5 1eC The Commonwealth of Massachusetts 11) Department of Industrial Accidents::=,-. ..2 vii,p-..._...F. _ff'._` 1 Congress Street, Suite 100 44.=�' 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): J r G C- r, /r"-1 Address: % JO Areal}? Odf City/State/Zip:5c pi OU t) //:6 Orl((t/ Phone#: 9 Are yo n employer?Check the appropriate box: Z//" Type of project(required): 1 1. 1 am a employer with / employ-:.(fill . d/or part-time).* 7. pew construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'camp. insurance required.) 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 9. iJ Demolition 10 ❑ Building addition 4.❑1 am a homeowner and wal be hiring contractors to conduct all work on my prope . I will ensure that all contractors either have workers'compensation insurance or are sol' 11.[] Electrical repairs or additions proprietors with no employees. 12.Lj Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contactors listed on the:I. ched sheet13.[I]Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.0 We are a corporation and its officers have exercised their right of exemp'•on per MGL c. 14.❑Other 152,§1(4),and we have no employees. [No workers'comp.insurance -. ired.] *Any applicant that checks box t 1 must also Ell out the section below sho :their worker'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all wor and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check this box must rrr?rhed an additional sheet shawl,g the name of the sub-contractors and state whether or not those entities have. employees. If the sub-contractors have employees,they must provide err workers'comp.policy number. I am an employer that is providing workers'comp• ••ion insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy Il or Self-ins.Lic.4: Expiration Date: Job Site Address: / '-'7 Ce4/"Jhe —; ' /`, ' City/State/Zip:S L ,,}2-Q70 b iMilT Attach a copy of the workers' compensa• on pricy declaration page(showing the policy numhe and expiration date). Failure to secure coverage as required s ter MGL G. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well . civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. A copy of th'. statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u t ►1 s ' -• .enalties of perjury that the information provided,above is true and correct. Si2nature: /d--.---d--------- Date: j i - _.... 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*4: 1 i