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��_+ � 1Jrpartmrnl t of ier reau;rs Permit No.
_�(( Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Rev.I/071
(leave blank)
• APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
O All work to be performed in accordance with the Massachusetts Electrical Code(MEC).527 Chill 12.00
• (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7/1 1/2024
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) 1 Country Club Drive
Owner or Tenant Jean Toomey Telephone No.508-751-2284
d Owner's Address Same as Above
uj Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate Box)
Purpose of Building Utility Authorization No. 18044421
N Existing Service 100 Amps 120/240 Volts Overhead Undgrd❑ No.of Meters 1
ill New Service 200 Amps 120 /240 Volts Overhead� Undgrd❑ No.of Meters 1
co• Number of Feeders and Ampacity
Q Location and Nature of Proposed Electrical Work: Remove and replace electric meter and service
panel in basement.Upgrade to 200 amps.
Completion of thefollowingtable may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.or Kota)
Traos(ormers KVA
No.of Luminalre Outlets No.of Hot Tubs Generators KVA
Pool Above In- No.of Emergency Lighting
No.of Luminaires Swimming 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
leittatiag Devices
No.of Ranges No.of Air Cond. Toosl No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
P Totals: Detection/Alertin Devices
Loc
al❑M Counicooec6oipal n ❑Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters Signs Ballasts No.o nr's enr E si?a)eni.
No.Hydromassage Bathtubs Na.of Motors Total HP Telecom n c opp _ ��rr E D
No.o' �dr'E ulxk�t••-
OTHER:
Attach additional detail if desired,or a.re lire heNtie2ta Wiles
Estimated Value of Electrical Work: (When required by municipal policy
Work to Start: 7/29/2024 Inspections to be requested in accordance with MEC Rule ID.WI upnal®m$elaaTM E NT
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of•Ifl♦tri cat worc-mav r<_tr-mnless
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 ❑ OTHER 0 (Specify:)
I certify,under the pains and penalties of peijury,that the information on application is true and complete.
FIRM NAME: Atlas Ener ies LLC LIC.No.:22617 A
Licensee: Paul McGrath Signature LIC.NO.:54687 B
ill applicable,elver"exempt'.in the license number line.) Bus.Tel.No.•774-602-0938
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 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 PERMIT FEE:S
Signature Telephone No.
The Commonwealth of Massachusetts
1 -►_a—
Art Department of Industrial Accidents
=��1= 1 Congress Street, Suite 100
='s 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): Atlas Energies L LC
Address: 19 High Noon drive
City/State/Zip: Centerville, MA 02632 Phone#: 774-602-0938
Are you an employer?Check the appropriate box:
Type of project(required):
1.111 I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 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. t 9. El Demolition
❑ y [No workers'comp.:nsurance required.]
4.❑ my
I am a homeowner and will be hiring contractors to conduct all work on property. I will 10 n Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.']Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We area 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_
r 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$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:
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#: