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HomeMy WebLinkAboutBLDE-23-003530 Commonwealth of Official Use Only :''' A Massachusetts Permit No. BLDE-23-003530 ...--' • 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:12/28/2022 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) 41 NEARMEADOWS RD Owner or Tenant HALLET REALTY LLC Telephone No. Owner's Address 12 COMSTOCK WAY, SOUTH WALPOLE, MA 02071-1055 Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appro late Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 Undgrd 0 4 of Meters New Service Amps Volts Overhead 0 Undgrd 0 of Meters N, Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Kitchen remodel, add recessed fixtures in living room and repla'e p el. Ci" Completion of the following table may be waive fie of IVires. No.of Recessed Luminaires 16 No.of Ceil:Susp.(Paddle)Fans No.of i Transformers J No.of Luminaire Outlets No.of Hot Tubs Generators No.of Luminaires Swimming Pool Above 0 In- ❑ No.of Emergency Lighting grnd. grad. Battery Units No.of Receptacle Outlets 12 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 5 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges 1 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 1 Space/Area Heating KW Local ❑ Municipal 0 Other: Connection No.of Drpers 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: 12/30/2022 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: Jonathan R Niland Licensee: Jonathan R Niland Signature LIC.NO.: 21103 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address:33 MARTIN ST, PAWTUCKET RI 028613420 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 Telephon No. PERMIT FEE:$75.00 /tea de_ &Jau.4 s/C,u...-..J fzk9kft ,lier A evdz. r11 g,� `O Commoncusatth o f niaeeachuesfle Official Use Only '' ' cc�� c�77 Permit No. Ez 3 - 3S3O - JJspartmsni o`.}irs Servicse Occupancy and Fee Checked • ,:' BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07} leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK J 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: ).)1 , kCity or Town of: =_Les+ lay �tl; To the Inspector of Wires: y By this application the undersigned gives notice of his or her intention to perform the electrical work described below. gLocation(Street&Number) 4 u f-tl-\.e(1,A,n _, \<c\_ c Owner or Tenant (j1 t d e y \c \k. Telephone No. d Owner's Address Solt' c Is this permit in conjunction with a building permit? Yes ai No C (Check Appropriate Box) S; Purpose of Building Kc'c t C-('c t�t,( Utility Authorization No. rt' Existing Service Amps / Volts Overhead n Undgrd No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters SNumber of Feeders and Ampacity Location and Nature of Proposed Electrical Work: KOC1w(-) ce_mocke , a Ati \i'(v •. 4-1, 1( ilk) Ck X—Ca f•F - 2V ar FAN��- c 3o c_r.ec -T vl Completion of the following table may be waived by the Inspector of Wires. att l.l.i No.of Recessed Luminaires 14.. No.of Ceil:Susp.(Paddle)Fans Tranf Total 'y: Transformers KVA nNo.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lightinggrnd. grnd. Battery Units �x No.of Receptacle Outlets i 9 No.of 011 Burners FIRE ALARMS No.of Zones z No.of Switches , No.of Gas Burners "No.of Detection and Initiating Devices 11 No.of Ranges 1 No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alertin Devices No.of Dishwashers r Space/Area Heating KW Local 0 Conne nice p ction other 0 o Co No.of Dryers Heating Appliances KWSecurity Systems:* No.of Devices or Equivalent No.of Water No.of No.of Data WIring: W Heaters Signs Ballasts 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: V-1000 (When required by municipal policy.) Work to Start: tar_Fs0 .'; 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 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: Nt kay-v-i r `1PC-lr-� , L�( LIC.NO.: j LI jC Licensee: JOr't ci\ VI a1\1\ckr't(1 Signature , !ii Vt, LIC.NO.: Z I toZ-,4 (If applicable,enter"exempt"in the license number,(ine.) Bus.Tel.No.. )P-i7 S'-t S 1(c, Address: 'g Ste '�� . 1 VAASA''L''C) k`t U L I G , 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 Signature Telephone No. PERMIT FEE:$ The Commonwealth of Massachusetts = / Department of Industrial Accidents =i"e1= 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 Leaiblv Name(Business/Organization/Individual): 1.4%Varuj C I L L(I_ Address: 73$' City/State/Zip: P'Ar-k,e\cc) M0. 021 D Phone#: 11 Li 25l 1 S S1 b Are you an employer?Cheek the appropriate box: Type of project(required): I.❑Iam a employer with employees(full and/or part-time).y 7. ❑New construction 2.2 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required]t 9. ❑Demolition 10❑Building addition 4.❑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.U4 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 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0We area corporation and its officers have exercised their ri t of exemption 14.❑Other gh Pn per MGL c. 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. 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: 41 NCa(fT1-e idolkaS Q d City/State/Zip:t&)l 16tcr otti-j-1— fs--& 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. Signature: ) Date: 1 a.'j q a. Phone#: 2 S l{S S1 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 6.Other Contact Person: Phone#: A CC)RL CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) \.. 12/20,22 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Karen E Frazao Frazao Insurance (A/C.No,Ext): 608-639-6384 FAX No): 608-667-6610 146 Central Avenue E-MAIL Seekonk,MA 02771 ADDRESS: karen@frazaoinsurance.net INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Mapfre Insurance Co INSURED INSURER B: The Hartford Niland Electric LLC INSURER C: Twin City Fire Insurance Company Jonathan Niland INSURER D: Citation Insurance 238 Steere Street Attleboro,MA 02703 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE 10 REN 1ED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 60,000 MED EXP(Any one person) $ 10,000 A Y Y 8008030017362 08/21/22 08/21/23 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 PE�X POLICY J LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 600,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ D OWNED SCHEDULED Y L06801 11/28/22 11/28/23 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y(N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 C OFFICERJMEMBER EXCLUDED? N N/A Y 08 WEC ANGSW9 10/16/22 10/16/23 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 It yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS(LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Yarmouth Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORAT O rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD