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HomeMy WebLinkAboutBLDE-26-551- - Commonwealth of Massachusetts Official Use Only . , !i Permit No. J-i4j�f=-a26 •S 5 et Department of Fire Services [F-J` Occupancy and Fee Checked ' / BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (leave blank) 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,AcL INFORMATION) Date: 0 cf-c-/ u-6 City or Town of: Ya-o-rh 0,:{4 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) /0 7 /-'/C,-.5-a4- S-fvee—± Owner or Tenant Gal nFy '<ciIAt_yy,Q�I.crI tvv6-C;�e Ic�s Q) ,lac! eTelephoneNo.S4�"5.2`? 3cf44 Owner's Address Pc 0, a�X D-EAS Or"(evd`. /�!i1 op-6 s3 Is this permit in conjunction with a building permit? 0g0,0 No (Check Appropriate Box) Purpose of Building 2e_S'C.t r5I, .( Utility Authorization No. Existing Service Amps / Volts Overhead 0 Undgrd❑ No.of Meters New Service Amps / Volts Overhead 0 Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: l-E,w sjc/45e_ SCet t,Yj , IX y�/� a o[GQ following table may be waived y the inspector of Wires. o.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No. sfo Total Transformers KVA?,P�a c*)o.of Luminaire Outlets Na.of Hot Tubs Generators KVA Above In- No.of Emergency Lighting ..�.1! Np."of Luminaires Swimming Pool grnd. ❑ grnd. ❑ Battery Units U" c''�fb:oPReceptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones / it: No.of Detection and �� -!�,_. _ofiSwitches11 No.of Gas Burners Initiating Devices Total +fir�A Q�Ranges No.of Air Cond. Tons No.of Alerting Devices g Nu.of Waste Disposers Heat Pump Number Tons .KW__ _ No.of Self-Contained S P Totals: - Detection/Alerting Devices Municipal ,,, 7 No.of Dishwashers Space/Area Heating KW Local❑Connection "�CFr a7� No.of Dryers Heating Appliances KW Security Devicres or Equs:* ivalent t- No.of Water KW .No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.HydromassageppBathtubs No.of/M�ootors / Total HP 1 ,�([/No.of DeviIces or Equivalent OTHER: F{00A s�t� &c-'([ • , 1/'aid �os.rfpe,-ir,ua l ��✓!tc"Tic., (I'd- X Uv Attach additional detail if desired;arias required by the Inspector of Wires. Estimated Value of Electrical Work: 6,o oo — (When required by municipal policy.) Work to Start: ©°f-P-'' -6 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 h 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: Seaside Alarms inc. LIC.NO.: 1317C Licensee: Robert K.Boucher Signature( 's Pars,os„TLIC.NO.: (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: ;08-t94-0599 Address: 1265 Route 28.South Yarmouth,MA 02664 Alt.Tel.No.: *Security System Contractor License required for this work;if applicable,enter the license number here: S-0046 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)0 owner 0 owner's agent. Owner/Agent PERMIT FEE:$ �S Signature n Telephone No. OCC4-?Se-ce.-Pt.cPCi v+1S, ht The Commonwealth of Massachusetts Department of Industrial Accidents mire - 1 Congress Street, Suite 100 _ saw . 1' wits MI Boston, MA 02114-2017 mire www.mass.gov/dia 11 ot-kers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING ALITIIORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Seaside Alarms Inc. Address: 1265 Route 28 City/State/Zip: South Yarmouth, MA 02664 Phone#: 508-394-0599 Are you an employer?Check the appropriate box: Type of project(required): I 0 i am a employer with 19 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.] 9. ❑Demolition 3.01 am a homeowner doing all work myself.INo workers'comp insurance required.] 10 El Building addition 4.D I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I L❑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.: 14.0Other Security&Fire Alarm 6.❑We are a corporation and its officers have exercised their right of exemption per MCI-c. 152,*1(4),and we have no employees.(No workers'comp.insurance required.) • *Any applicant that checks box Il I must also fill out the section below showing their workers'compensation policy information. +I lomeowners 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: Hartford Fire Insurance Co. Policy#or Self-ins.Lic.#: 08WECAE7ZU7 _ Expiration Date: 2/25/27 Job Site Address: All sites 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 MG!,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 S250.00 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 perju hat the information provided above is true and correct. Signature: President _2/2 2 Phone#: 5 4464)1 PbIlik 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#: ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 02/26/2026 THIS TIFICATE 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 CONT:CT Emily Montgomery The Hilb Group New England,LLC PHONE (800)640-1620 A FAX (A/C,No,Ext): ( No): E-MAIL emontgomery@hilbgroup.Com ADDRESS: 973 lyannough Road INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: SiriusPoint Specialty Insurance Corp 16820 INSURED INSURERS: Safety Indemnity Insurance Co 33618 Seaside Alarms,Inc. INSURER c: Twin City Fire Insurance Co 29459 1265 Route 28 INSURER 0: INSURER E: South Yarmouth MA 02664 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 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. INSR ADDL SUHR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCEw INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 �/ DAMAGE TO RENTED 100,000 1 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ X DED:$10,000 MED EXP(Any one person) $ 5,000 A ESP-SP-AL-GL-0000009-02 02/25/2026 02J25/2027 PERSONAL&AOVINJURY $ 1,000,000 2 000 000 GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE ; , , X PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JECT $ OTHER: - COMBINED SINGLE LIMIT $ 1,000,000 AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED %,/ AUTOS 6222107 02/25/2026 02/25/2027 BODILY INJURY(Per accident) $ AUTOS ONLY " PROPERTY DAMAGE XHIREO " NON-OWNED N ONLYY (Per accident) $ AUTOS ONLY /� AUTOS g UMBRELLA LIAB X OCCUR EACH OCCURRENCE s 1,000,000 y A EXCESS LIAB ESP-SP-AL-SX-0000007-02 02/25/2026 02/25/2027 AGGREGATE $ 1,000,000 — X CLAIMS-MADE DED X RETENTION$ 1,000,000 $ WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY YIN 1,000,000 ANY PROPRIETORJPARTNERIEXECUTIVE N N f A OBWECAE7ZU7 02/25/2026 02/25/2027 E.L.EACH ACCIDENT $ C (Mandatory OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 1,000,000 IIf yes,descnbe inand 1,000,000 DESCRIPTION under E.L.DISEASE-POLICY LIMIT S _ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is 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 thecoverage 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1 �' • ►t i • ► _t _ ..:. _^-- • • ►i`:, . r I � DIVISION OF OCCUPATIONAL LICENSURE •'VISIONOF OCCUPATIONAL LICENSURE BOARD OF BOARD OF ELECTRICIANS ELECTRICIANS ISSUES THE FOLLOWING LICENSE REG ISSUES THE FOLLOWING LICENSE ;W SYSTEMS CONTRACTOR BUSINESS REGISTERED SYSTEM CONTRACTOR j5 z ROBERT K BOUCHER SEASIDE ALARMS INC 0 cn 1265 ROUTE 28 1265 ROUTE 28 w S YARMOUTH, MA 02664-4455 --A W S YARMOUTH, MA 02664-4455 •1'�; `' 1317 C 07/31/2028 795340 4177 C1 07/31/2028 793832 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER V - • M • 1 ' T. • ►i ; . : a -1■ _.__-- DIVISION OF OCCUPATIONAL LICENSURE Commonwealth of Massachusetts BOARD OF 17 Division of Occupational Licensure ELECTRICIANS Securir 4h `Lirers ISSUES THE FOLLOWING LICENSE tu REGISTERED SYSTEM TECHNICIAN SS-003436 I spires: 11/20/2026 ROBERT K BOUCHER •,e 6 r ' in ROBAT i1L. • 1265 ROUTE 28 ItE lo" J ; S YARMOUTH, MA 02664-4455 v z SELF ? , - ' v b'#Cll.1.'E'd:1'.1_-' t 463 D 07/31/2028 796748 Commissioner etti. „ LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER