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Home My WebLink AboutBLDE-23-00269 Commonwealth of Official Use Only • Massachusetts Permit No. BLDE-23-000269 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:7/18/2022 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) 7 SMITH RD Owner or Tenant MACROBERTS RICHARD Telephone No. Owner's Address CIO GANDERSON NORMA J, 5268 WETHERSFIELD RD, JAMESVILLE, NY 13078 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: Kitchen, laundry&garage. 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 No.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 ❑ 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 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: 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: $75.00 f- I/34Iyv RECEIVED rel-64974-1Kriqk F. JUL 15 2022 .-Conn oawealth of Massachusetts ' Official Use Only�_•DEPARTMENT 23-oz.�9 B Permit No. B"_�=;---Qeparlmenr of Fires Services fit BOARD OF FIRE PREVENTION REGULATIONS Occupancy and eeChecked (Rev.9/05)(leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code( ,527 MR 12.00 , (PLEASE PRINT IN INK OR TYPE ALL INFO ATION) Date: 7 /5]o L -. City or Town of: wow A aN ) To the Insp ctor of Wires: I it By this application the undersigned gives notice a his or her intention to perform the electrical work described below: Location(Street&Number) 7 ..S.'hi iTin Ka 3333.... Owner or Tenant A' ,v7 71 G N SO" Telephone No. Owner's Address Solio�C GU AILS1) 1C- -e'irk QO vJ n4O(/l/le Nt�', /3Q7 Is this permit in conjunctloB'with building permit? Yes(r No❑ (Cheek,►�ptopnale Boo) 1 Purpose of Building / Too' Utility Authorization No. �l FEEx'sgnB Services_ Amps lDI /_Volts Overhead❑ Undgrd D No.of Meters CJ allow Service I e O Amps 171'do Volts Overhead Undgrd❑ No.of Meters ' 1 Number of Feeders and Ampadty )� � Location and Nature of Proposed Electrical Work: kri'6, L At.n 19 K�yp— r F v Completion of the following table may be waived by the Inspector of Wirer. f( No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans jronsformers Total No.of Luminaire Outlets No.of Hot Tuhs Generators KVA No.of Luminaires Swimming Pool dd ta'• B EUi q Lighting No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones 'No' No.of Detection and No.of Switches No.of Gas Boners Initiating Devices f) No.of Ranges No.of Air Cond. Total l ns No.of Alerting Devices \J No.of Waste Disposers Heat Pump Number Tons._ KW No.of Self•Coutaioed r pose Totals: Detection/Alerting Devices .�\�\d{/r No.of Dishwashers Space/Area Heating KW Local❑Municipal Other Connection No.of Dryers Heating Appliances KW Seeurity S items:• }� No.at�or Equivalent I , No.of Water Heaters i KW No.o Sfgns NBallasts o.of Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications of Deuvices of Wiring: OTHER: Attached additional detail if doired.or as required by the Inspector of BSres. Estimated Value oJ Ele cal Work: (When required by municipal policy.) Work to Start:yd/ Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE V GE:Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liabilityinsurance 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 0 OTHER (Specify:) I certify,under the ru an¢pens s of quey,that the information on this application is true and complete. j4 lc y/� FIRM NAME: G-C,IG f C,...) LIC.NO.:/_-r /� Licensee:7�-C.1G 6rt .N Signature LIC.NO.:etz�r� �J4 (If a��.ble,ent"g pmp"in the license Di-4 �m line.) Q I) / Bus.Tel.No.: QW`�7. o`.S / t71. J_ t4 jCJ T 0.1(OL V Alt.Tel.No.: 'Security System Contractor License required Irk this work;if api!ilicable,enter the license number here: OWNER'S INSURANCE WAIVER:I am aware that the Licensee does nor 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:$ . The Commonwealth of Massachusetts = Department of Industrial Accidents 1 Congress Street, Suite 100 6 Boston, MA 02114-2017 wti um,,,-' www.tnass.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/Individua!): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.17 I am a employer with employees(fall and/or part-time).* 7. 0 New construction 2.E I am a sole proprietor or paretership and have no employees working for me in 8. 111 Remodeling any capacity.[No workers'comp.insurance required.] 9. [ Demolition 311 I am a homeowner doing all work myself.[No workers'comp. insurance required.]t f 10 7 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.7 Plumbing repairs or additions 5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and itsofficers have exercised their right of exemption per MCL c. 14.0 Other 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box fr 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: Policy#or Self-ins.Lie.#: 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 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. Sienature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official. k 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 n: ��