HomeMy WebLinkAboutBLDE-25-1558 BLD. 1 14 Official Use Only
Commonwealth of Massachusetts Permit No.: F a5-1555'
_w Department of Fire Services Occupancy and Fee Checked:
�` BOARD OF FIRE PREVENTION REGULATIONS [Rev.I/2023]
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
City or Town of: YARMOUTH Date: JN.:,ve,+-' " 7' 2.42c-•
To the Inspector of Wires:By this application,the undersigned gives notices of his or her intention to perform the electrical work described below.
Location(Street&Number):'u0 i,ch..d-1,0,+11 10 Qirt[O.p'L I e4lr�,Unit No.: P-;;
Owner or Tenant: f4)i,'s.� ecr'.o 6-,04P ' Email: '''''
Owner's Address:>�c ,alr -i7 is .J /7 Phone N .: . t2 775- S5.75;
Is this permit in conjunction with a building permit?(Check appropriate box)Yes❑ No Permit No.:
Purpose of Building: (ofi°a Utility Authorization No.: C-�p(IG L�
Existing Service: I p U Amps //c /??- Volts Overhead❑ Underground[2" No.of Meters: -2-
New Service: Amps / Volts Overlie ❑ Underground❑ No.of Meters:
Description of Proposed Electrical Installation: ts'i(Z •a'n2,/ '/'o WPII- UriS filkt ow ei EV&ZS a i tb'
Okc ekserT air eN_, Ntto r itekte/Rt-Pu,te— meol re(rer- o , wale
Completion of the following table may be waived by the Inspector of Wires. A i✓E g-
No.of Receptable Outlets: No.of Switches: Generator KW Rating: Type:
No.Luminaires: No.of Recessed Luminaires: No.Wind Generators: Wind KW Rating:
No.Appliances: KW: No.Water Heaters: KW: No.Transformers: Total KVA:
Space Heating KW: Heating Equipment KW: No Motors: Total HP: Total KW:
No.Heat Pumps: Total KW: Total Tons: Fire Alarm System❑ No.of Devices:
Swimming Pool:In-Grad.❑ Above-Grad.0 Hot-Tub 0 No.of Self-Contained Detection/Alerting Devices:
No.Oil Burners: No.Gas Burners: Video System 0 No.of Devices:
No.Air Conditioners: Total Tons: Telecom System 0 No.of Outlets:
No.Energy Storage Systems: KWH Storage Rating: Security System 0 No.of Devices:
Solar PV KW DC Rating: Solar PV KW AC Rating: No.of Electric Vehicle Supply Equipment:
No.of Modules: Roof-Mount 0 Ground-Mount 0 Level I 0 Level 2 0 Level 3 0 Rating:
OTHER:
Ne---6o C/ t Eve c-if er" 2 -tr r„-2ei / i,�i ,
Attach additional detail if desired or as required by the Inspector of Wires.
Estimated Value of Elec teal Work: Z.2 r (When required by municipal policy)
Date Work to Start:�// 19 Inspections to be requested in accordance wills MEC Rule 10,and upon completion.
• FIRM NAME: 1) Si rD P Ci s E-2eLo C A-1❑or C-I❑LIC.No.:r?>Z7`'
Master/Systems Licensee: LIC.No.:
Journeyman Licensee: • LIC.No.:
Security System Business requires a Division of Occupational Liccnsure"S"LIC. S-LIC.No.:
Address: ��//I,,IF Mgia A5 1D 1.r IUE i - /s i-/ /"4- 02 73
Email: bc�"to/`fJ eta @ Vrh./-. Co/1A- ' Telephone No.: (6n) 7L cog
I eert ,under the pains an��d��a"ns�i/ties of perjury,that th kfornration pr this application is true and corn,let.
Licensee:I N1 Cl.�c-�r11/) Print Name: f\J�---VJ/ G��(\ Cell.No.1 Ug72-Co()e
INSURANCE COVERAGE:Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee '
. provides proof of liability including"completed operation"coverage or its substantial equivalent.The undersigned certifies that such coverage
is in force and has exhibited proof same to the permit issuing office. �,,,. A ,—
CHECK ONE: INSURANCE ofBOND❑ OTHER❑ Specify: fXZ4T
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: Tel.No.:
Signature: Email.:
1(5 0 . CK,C1rl * 35ga
'_ COMMONWEALTH OF j : A W 1 ETTS;
• DIVISION OF OCCUPATIONAL LICENSURE
r•
BOARD OF
ELECTRICIANS
ISSUES THE FOLLOWING LICENSE
REG JOURNEYMAN ELECTRICIAN
DESMOND P CLIFFORD z
4 MERRYMOU.NT.RD
W YARMOUTH MA 02673.4853
z
;ur
U
33276 E 07/31/2028 764879
LICENSE NUMBER EXPIRATION D.TE SER• UMBER •
N.
WP Safety Insurance BUSINESSOWNERS DECLARATIONS `
AUTO•HOME•BUSINESS Policy Period
Safety Insurance Company Policy Number From To
BMA0030907 03/23/2025 03/23/2026
12:01 AM.Standard Time at the described bation
Transaction
Renewal Declarations
Named Insured and Mailing Address Agent
DESMOND CLIFFORD RAPLANSKY INS AGY INC
DHA DESMOND P CLIFFORD ELECTR 1152 WASHINGTON ST
14 MERRYMOUNT RD DORCHESTER MA 02124
WEST YARMOUTH MA 02673
Telephone: 617-296-0350 69642
Form of Business: INDIVIDUAL Type of Business: ELECTRICAL WORK WITHIN BLDG
DESCRIBED PREMISES
LOC BLDG ADDRESS AUTOMATIC INCREASE
001 14 MERRYMOUNT RD WEST YARMOUTH MA 02673 6%
PROPERTY
LOC BLDG COVERAGE VALUATION DEDUCTIBLE LIMIT OF
INSURANCE
001 001 Personal Property Replacement Cost $ 500 $ 3,120
Deductible shown above applies per any one occurrence
BUSINESS INCOME:Actual Loss Sustained Not Exceeding 12 Consecutive Months.Ordinary Payroll 60-Days.
LIABILITY AND MEDICAL EXPENSES
Except for Fire Legal Liability,each paid claim for the coverages listed reduces the amount of insurance we provide
during the applicable annual period.
BUSINESS LIABILITY COVERAGE LIMITS OF INSURANCE
Liability $ 1,000,00o Per Occurrence
Medical Expenses $ 10,0 o o Per Person
Fire Legal Liability $ 10o,000 Any one Fire/Explosion
ADDITIONAL COVERAGES
Some property coverages are subject to deductibles specified in the policy forms.
Optional Property Coverage Description Limits of Insurance
LOC BLDG DESCRIBED COVERAGES
001 001 Contractors Tools - Blanket Basis $ 5,000
001 001 Contractors Installation Coverage $ 10,000
Contractors Enhancement
Optional Liability Coverage Description Limits of Insurance
Contractors-payroll $35,700
Contractors Liability Endorsement
CHANGE IN PREMIUM: $ TOTAL PREMIUM: $ 1,290
BPDEC2022
INSURED