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HomeMy WebLinkAboutBLDE-25-1486 ellit—oln Commonwealth of Massachusetts Official Use Only Permit No.: 1e } + t Department of Fire Services Occupancy and Fee Checked: 7 _ BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/2023] APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),5 7 C 12.00 City or Town of:_YARMOUTH Date: I/ 3 .SS 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&NAmber): I I"RNY OIL S CI R Unit No.: Owner or Tenant: Kbbetr f1 AU&Si 4 PW� � Email: RO 15 AAl 4 3 8 C VMfl 1 L'cool Owner's Address: 1 AN K-S Phone No.: 1 7• sr/ 1.7 55 9 Is this permit in conjunction l' )on with a buildingOf permit?(Check appropriate box)Yes 0 No 0 Permit No.: Purpose of Building: Rt<St'o4d Lt Utility Authorization No.: a3 4 537 / G. Existing Service: I D U Amps 00 ?VOVolts Overhead 0 Underground 0 No.of Meters: New Service: aoc Amps I Pi 'Vo Volts Overhead 0 Underground,® No.of Meters: I Description of Proposed Electrical Installation: U P&? D ISTt N& /0 a AAA.P Sz2 Ji Cg- —re) c9-00 A.tNk Q , Completion of the following table may be waived by the Inspector of Wires. 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 0 No.of Devices: Swimming Pool:In-Grad.❑ Above-Gmd.0 Hot-Tub❑ 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 ❑ No.of Devices: Solar PV KW DC Rating: 12.. olar PV KW AC Rating: � gtNo.of Electric Vehicle Supply Equipment: No.of Modules:30 Roof-Mount Ground-Mount 0 Level 1❑ Level 2 0 Level 3 0 Rating: OTHER: Attach additional detail if desired,or as re fired by the Inspector of Wires. Estimated Value of Ele tric Work: re ' (When required by municipal policy) Date Work to Start: I ) • •� Inspections to be requested in accordance with MEC Rule 10,and upon completion. FIRM NAME: Q ei U . , Lf.6 I t:. A-1 0 or C-1 0 LIC.No.: illeM Systems Licensee: LIC.No.: c /'?(A. Journeyman Licensee: LIC.No.: S i ea7 Security System Business requires a Division of Occupational Licensure"S"LIC. S-LIC.No.: Address�:--� ` /y �� t �/ 1 1 �1Y� ` • `�`� `] Q, Email:L/�LV kaa L.La ZC L0�� PA u'C eT Iephone No.: 7'6 1 • h-t-+) • G� l I certify, the pains and p Itie of perjury,that the information on this application is true and complete. Licensee: Print Name:`�tAJtr] ....T. ©'RS111 Cell.No.:7 a et I - 771• /?( /- INSURANCE COVE E:Unless . ed by the owner,no permit for the performance oectrical 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 of ame to the permit issuing office. ONE: INSURANCE BOND 0 OTHER 0 Specify: 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 0 Owner/Agent: Tel.No.: Signature:_ Email.: / ® DATE(MM/DDIYYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE ��. 05/30/2025 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 Nancy Hafford NAME: State Farm NancyHafford PHONE 207_641-2186 FAX (A/C,No,Ext): (A/C,No): O 960 Sanford Road E-MAIL Want .hafford.' 68 statefarm.com O.O . ADDRESS: y � INSURER(S)AFFORDING COVERAGE NAIC# Wells ME 040901679 INSURER A : State Farm Fire and Casualty Company 25143 INSURED INSURER B : O'REILLY ELECTRIC, LLC INSURER C : 155 ROSE WAY INSURER D: _ __ INSURER E: WELLS ME 04090.7659 INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIF" 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 3E 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 ADD SUB POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD W /Y VD POLICY NUMBER (MM/DDYYY) (MM/DDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �/ DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 i MED EXP(Any one person) $ 5,000 A I N N 99-BD-R363-7 03/15/2025 03/15/2026 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 � PRO- 1 X X POLICY PRODUCTS COMP/OP AGG $ 2,000,000 L J=CT L_ LOC $ OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ___, OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPERTY DAMAGE AUTOS ONLY AUUTTOSS ONLLYY HIRED NON-OWNED (Per accident) $ UMBRELLA LIAE; OCCUR EACH OCCURRENCE $ -_ EXCESS LIAB 1 CLAIMS-MADE AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION I PER OTH- $ STATUTE , ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A E.L. DISEASE EA EMPLOYEE $ (Mandatory in NH) If yes, describe under E.L. DISEASE POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule, may be attached if more space is required) Electrical services. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Beach Dreams Cottages 412 Post Road AUTHORIZED REPRESENTATIVE Wells ME 04090 � This form was system-generated on 05/30/2025 ©1988-2015 ACORD CORPORATION. All rights reserved. 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