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HomeMy WebLinkAboutBLDE-23-003519 RMV °`°'dr, ) Commonwealth of Official Use Only V Massachusetts Permit No. BLDE-23-003519 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.l/07J — 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 IN OR TYPE ALL INFORMATION) Date:12/28/2022 — City or 1 own of: YARMOUTH To the Inspector of Wires: By this application the t idersigned gives notice of his or her intention to perform the electrical work describedtelow. Location(Street&l\amber) 1070&1074 ROUTE 28 (Ipg:,i JlsA✓) Owner or Tenant )AVENPORT DEWITT TR Telephone No. Owner's Address 0 NORTH MAIN ST, SOUTH YARMOUTH, MA 02664 Is this permit in conji Iction with a building permit? Yes 0 No 0 (Check Appr ate Box) Purpose of Building Utility Authorization No. _ Existing Service Amps Volts Overhead ❑ Undgrd 0 o.of eters, f - (.- New Service Amps Volts Overhead 0 Undgrd 0 •" ' Number of Feeders and Ampacity f Location and Nature of Proposed Electrical Work: Demo wiring and temp lighting. �' , d Completion of the following table may be wai c r of Wires. No.of No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers 'OP No.of Luminaire Outlets No.of Hot Tubs Generators No.of Luminaires Swimming Pool Above ❑ In-d. ❑ No.of Emergency Lighting grnd. grn Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Gas Burners No.of Detection and No.of Switches Initiating Devices No.of Air Cond. Total No.of Alerting Devices No.of Ranges Tons Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alertine Devices Space/Area HeatingKW Local 0 Municipal 0 Other: No.of Dishwashers P Connection HeatingAppliances KW Security Systems:* No.of Dryers PP No.of Devices or Equivalent No.of Water KW No.of No.of Ballasts Data Wiring: Heaters Siens No.of Devices or Eauivalent 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. required bymunicipal policy.) Estimated Value of Electrical Work: (Whenq P P y' Work to start: 12/23/2022 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 ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LANCE A MACENERNEY LIC.NO.: 11149 Licensee: Lance A Macenemey Signature (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: Address: 126A MID TECH DR,W YARMOUTH MA 026732560 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: $100.00 I ' A C,satoosivoaK el Via � e Only n—'-.... :., e[J.partmswt o�,tint Jawicss No. , 23 .-36 4 1'n Occupancy and Fee Checked `-.. :�, BOARD OF FIRE PREVENTION REGULATIONS^ [Rev.Permit1/07] O c 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 INFO TION) Date: I 2-1 P 31 ,--1-" City or Town of: Wrel boa ) 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) 10<6 Owner or Tenant Ofk 1(P .171)v,e � Telephone Na. Owner's Address T CY . Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) • 0 Purpose of Building Utility Authorization No. J, Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead 0 Undgrd❑ No.of Meters Number of Feeders and Ampacity Q Location and Nature of Proposed Electrical Work p('lrlo \ l nes \ YIS-Vc. ( t 1 i t l 1 / Completion of the follow table mg be waived by the Insisedor of Wins. Vi No.of Recessed Luminaires No.of CeLSasp.(Paddle)Fans Trans of formers Total VA r1 No.of Luminaire Outlets No.of Hot Tubs Generators KVA A Above Ile- tvo.of LrkserSeney i.igltuag ^t No.of Luminaires ��g Pod grad. 0 fund. ❑ Bey Units No.of Receptacle Outlets No.of Oil Barkers FIRE ALARMS No.of Noses of Detectiou and z- No.of Switches No.of Gas Burners O"Initiating Devices otal i L1 ' No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Self-Contained No.of Waste Disposers HeatTotab: Number Tens KW Detection/Aiertina Devices No.of Dishwashers Space/Area Heating KW Local 0 C� El Other No.of Dryers Heating Appliances No.ofDevices or Eentivaiekt No.of Water -No.of KO.of Data Wiring: HeatersKW Signs Ballasts No.of Devices or S: No.Hydromrassage Bathtubs No.of Motors Total HP Tetecommankations No.of Devices or OTHER Attach adittiond detail tf desir+ed or as required by the hailer for of Wires. Estirnated Value of Electrical Work: (When required by municipal policy.) Work to Start 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 (Specif) is a,re and complete.I certify,under the and pelts p ry,that the information on this app . FIRM NAME: er eat e. C�Im LIC.NO.: A I 1 I�f Q licensee: III CcC he.Xf`e..`L Signature --- LIC.NO.: in the license number l fine.) Bus.Tel.No.:,_ `�'rt`5— (If applicable.enter"exempt' Alt.TeL No.: Address: *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 0 owner's agent. Signature/ Telephone No. 1 PERMIT FEE:$ AC& CERTIFICATE OF LIABILITY INSURANCE l DATE(""°°° THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 26/2022 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND,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 COTACT Martha Kenney,CISR Dowling 8 O'Neil Insurance Agency P +E (800)640-1620 FAX 973 lyannough Road � � WC,No ADDRESS: mkenney©hilbgroup.cem Hyannis INSURER(S)AFFORDING COVERAGE NAlE MA 02601 INsuRER A: Tri-State Insurance Co.of Minnesota INSURED 31003 INsueER e: Acadia Insurance Company 31325 FULLER ELECTRIC COMPANY,INC. 126A MID TECH DR INSURER C INSURER D: W YARMOUTH INSURER E: MA 02673-2560 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 CONDEION 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 AOOLSUBR LTR TYPE OF INSURANCE ASPMD POMCYNUIBER (POMMIDDIWYI'r (MWODIYYYY) LYrra X COMMERCIAL GENERAL LIABILITY IEACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR DMIAGETO RENTED PREMISES(Ea occurrence) $300,000 MED EXP 10,000 A ADV5450504-12 09/22/2022 09/22/2023 (Anyone Peron) $ 1,000,000 PERSONAL&ADV INJURY $ GENI.AGGREGATE LMRAPPDES PER: GENERAL AGGREGATE $2,000,000 POLICY®PR6 JECT LOC PRODUCTS-COMP/OP A°G $2,000,000 OTHER: $ AUTOMOBILE LABILITYCOMBINED SINGLE LIMIT $ 1,000,000 — ANYAUTO (Ea emaenm BODILY INJURY(Per person) $ A OWNED SCHEDULED _Hums ouLv vx ADA5450538-12 09/22/2022 09/22/2023 eo°ILV INJURY(Par aa...MI S X AUTOS ONLY /T.AUTOS ONLY PROPERTY DAMAGE $ - (Per eccidenn $ 100,000 x UYBREIJA LL1B X OCCUR EACH OCCURRENCE $5,000,000 A FX°EDS��LI IgIe CLAIMS,MADE ADV5450504-12 09/22/2022 09/22/2023 A���, $5,000,000 DEC I iy RETENTION$0 $ WORKERSCOMPENBATNIN X1 ER UTE AND EMPLOYERS'UIBIUTY Y'/N EL ANY PROPRIETOR/PARTNER/EXECUTIVE B oFFICEPUAEMOER IXQUDmiE N/A WCA5450514-12 09/22/2022 09/22/2023 EL EACH ACCIDENT $500,000(I1a11damry In NIB EL DISEASE-PAGlAPLOVEE S 500_004 ewee,RITTON under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIME $500,000 - DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remake Schedule,they be attached N mon space N required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsements.Nothing contained in the Certificate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth;Wiring Inspector ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Ir.—I I ©1988.2015ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD