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HomeMy WebLinkAboutBLDE-25-1528 _ Commonwealth of Massachusetts Permit No: Official Use Only Er—a,.— aQ' =Jill ` Department of Fire Services occupancy and Fee Checked: '' lrzoz3J BOARD OF FIRE PREVENTION REGULATIONS [Rev APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 C 12.00 City or Town of: YARMOUTH Date: Id 11 a S.-- To the Inspector of Wires:By this application,the undersigned gives notices ofhis or her to perform the electrical work described below. Location(Street&N ber): I'f m Rnl`4. O A ids CI KG I L Unit No.: Owner or Tenant: Ysabeg..-r poOeiZSorJ Email: Roe AA19Nf rf GI RIL.CoItil Owner's Address: I 1J j'RrJ`a- Of•} S C(Kc Ir Phone No.: Is this permit in conjunction with a building permit?(Check appropriate box)Yes 0 No❑Permit No.:pp Purpose of Building: 1?1s l Of rJ �/�i3 Utility Authorization No.: Existing Service: I 0 0 Amps /hI p Volts Overhead 0 Underground it No.of Meters: I New Service: Amps / Volts Overh El Underground El No.of Meters:/ Description of Proposed Electrical Installation: C I&Rto I)P/f`f-"Au rt rhos£m rt N r Wig,i i / i/- �o(l. Cetlt, 1 Ai STk/leTiofJ' --iSrRII Silb QHn/FL (i oA Completion of the following table may be waived by the Inspector of Wires. No.of Receptable Outlets:7 No.of Switches: I lU Generator KW Rating: Type: No.Luminaires: D_No.of Recessed Luminaires: a a 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.0 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❑ Ground-Mount 0 Level 1❑ Level 2❑ Level 3❑ Rating: OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: .3OoC' (When required by municipal policy) Date Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I',.NAME: CD.ka t €44.711I C A-I❑or C-1❑LIC.No.: h, a,/•ystems Licensee: LIC.No.: r-16? i A Joumeym�Licensee: LIC.No.: S/a"a 7�. Security System Business requires a Division of Occupational Liceosure"S"LIC. S-LIC.No.: Address: 1 5$goSf WA-a- twJ'Z It S ltil�' . Email: -- -7-o Kei 111..ao 10( 461 tMFlt L.Co✓A Telephone No.: 77I t 771.9176,f I certify,under the pains and patties of perjury,that the information on this application is true and complete. Licensee: Re Print Name: -'fist ) SO•l flI Cell.No.: 7 I '77/•5�6X INSURANCES R]KGE:Unless aived by the owner,no permit for the performance ofMectrical work may issue unless the licensee provides proof of liability including"completed operation"coverage or its substantial equivalent The undersigned certifies that such coverage is in force and has exhibited proof of a to the permit issuing office. CHECK ONE: INSURANCE BOND ElOTHER ElSpecify: OWNER'S INSURANCE W R:I am aware that the Licensee does not have the liability insurance coverage normally required by law.By my signature below,I hereby waive this requirement.I am the:(Check one)Owner❑ Owner's agent❑ Owner/Agent: Tel.No.: Signature: Email.: �° R E NOV 12 2025 BIB 'A i NT By 4....„ ..' -4, ,4- ...i,„,_ ...ICI:t(,,If,,, .;.,, . i -•;-••.,-•,:,_‘,•' - -7c1IN,11 ••,..4.1‘%:,--v-t:7.-_,‘, ;c.,..-.) . : 41.- - •$•••. Ir l t ', i'11r ..A.siJL. r r91, : -10©AAOFi kj> • ?inOW JA3IP r i'igo . ..' 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A - 1 , fkFlki4ii I i t . b A Al>iR s,, a caa•.>1 r .1e..301 a,. - itHkt J 'i9 (,c .t,4,9h 1-.nn 2N:y,AI i9lott+„:,,I:it,i91 1 wq?..n�yy.JY�i-1 a tc ..q6.4ua u ,-, rs:ur ., J. 1, 1. e'IX 34.3'?(y) - ,,a;ra/if ....,:.. ry .,. r,, ',ai v?il•d5Ifioi0Uiq 7�{fu.,.!r I::I •r 54dtnt `� 1} Aar Q SOS S 1 VON AC() CERTIFICATE OF LIABILITY INSURANCE O513011 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 p.oiicy(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 an this certificate does not confer ri9ht5 to the certificate holder in lieu of such endorsee nt(s). . PRODUCER CONTACT Nan., Hatford Sole Fara) Nancy Hafford PHONE 207-6E41-28B FAX Ate, No, EA : I�lo 3 Sanford r E-MAIL, - 6 •. s' ncanc ,hafford jws8as .CDITI ..._...,.._...�4-�..- INSURER(S)AFFORDING COVERAGE NAIC 4 ' + liS ME 040901679 INSURER A : State Farm Fire and Casualty Company 25143 INSURED INSURER B O'REILLY ELECTRIC, Li..0 . INSURER C : — _ __ 155 ROSE WAY INSURER a _ _ .w.._..._." .. _ _ . _______._ _. .... I INSURER E _ __..__• _ w .• �..,." WELLS ME 040907659 INSURER F : 1 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 PERK:AD-7 INDICATED NOTWTHSTANDING 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 ._w _ _ ___ m.�.Y ADD SUES ..._., _......_...,_ . ..._.. ,, I. _ Lit 1 TYPE OF INSURANCE INSI3 I'fl#"' `D POLICY NUMBER Jt MIDOfYYYVI LMM r LIMITS X COMMERCIAt..GENERAL LIABILITY EACH OCCURRENCE E 1 , U, Q3 I - CLAIMS-MADE L OCCUR 1 E REmI :.( I " ... MED EXP (Any one person) $ 5, A N N 09-BD'-R 363 7 , 03/15/202 t 03/15/2026 . I I�t P . :.r,IA , .6, DV INJURY t I Y . $ 1,000,00 _..,.. GENT AGGREGATE LIMIT APPLIES PER: GENERAL A GGREGATE $ 2.000 A 0.-.0O --, _ I t AX LOC PRODUCTS COMP/OP FCfi $ 2,000,000 .."‘ POLICY L 1,: OTHER. ., ... . . E NED . L AUTOMOBLE LIABILi.> ,t I s'tS� 4,l �t __ .._... _....._. ANY AUTO ! [ BODILY INJURY(Per perm) OWNED SCHEDULED BODILY iMj._SRY (Per accident)AU 'OS ONLY AUTOSCiP "I � �.... HIRED NON--OWNED i (Per � __..._.......__... _ AUTOS ONLY _ ,.,.• AUTOS ONLY } _ , f k 1 L ' EACH UMBRELLA LAE OCCUR G RENCE $ { i ......„ _ r EXCESS UAB H4MDE . AGGREGATE S - t IEI RETENTION i ... $ .-. r , �IMI .S Ct IPEI i A"# ON f PER QTH•.I_,STA UTE I }. .E£....__.._ 4 AND EMPLOYERS' LIABILITY I ANY PROPRIETOR/PARTNER/EXECUTIVE E:R/EXECUTIVE Y!N E.L.. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A E L I;-1i.Ei�f•,~"E.- EA EMPLOYE $ (Mandatary in NH) I ....:.. ,:,:...- " . 1'€.yes. descrthe under E I. DISEASE • POLICY LIMIT I $. ESCRIPTI 3N OF OPERATIONS be.-Av _ • DESCRIPTION OF OPERATIONS/ LOCATIONS (VEI•IICLES (ACORD 101, Additional Res arlL Schedule, ray be attached if more space is required) Electrical setvices. S t 3 Y ;{ .. CANCELLATION HOLDER wo m , ........... SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, aeamil Dreams Cottages , i 412 Post Road AU1HOF ZED REPRESENTATIVE A.. .:„,•ME 04090 c„,., ; This km was systam-geneated on 05/30/2025 Wells . .. 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 5 (ZOS'O ) The ACORD name and logo are registered marks of ACORDoi4 not? 155279 205 c 1 zap ir n n a c 0 ' m r v r v a as „« , f m t 1 m. T r i