BLDE-22-002475 d4., Commonwealth of Official Use Only
it1 Massachusetts Permit No. BLDE-22-002475
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev.1/07]
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/N INK OR TYPE ALL INFORMATION) Date:10/30/2021
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) 11 CROSBY ST
Owner or Tenant Larry Pincus Telephone No.
Owner's Address 11 CROSBY ST, SOUTH YARMOUTH, MA 02664
Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead 0 Undgrd 0 No.of Meters
New Service Amps Volts Overhead 0 Undgrd 0 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Replacement boiler&water heater.
C pletion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Padd an No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool A o In- No.of Emergency Lighting
gr ; grnd. Battery Units
No.of Receptacle Outlets No. f Oil Burners FIRE ALARMS No.of Zones
No.of Switches i 1�1 of Gas Burners 1 No.of Detection and
Initiatine Devices
No.of Ranges .o Air-Cond. oval / No.of Alerting Devices
No.of Waste Disposers at Pump Numb Tons W No.of Self-Contained
tale: Detection/Alertine Devices
No.of Dishwashers Space/Area Heating KW ❑ Municipal 0 Other:
k7.,),ocal Connection
No.of Dryers Heating Appliances K Security Systems:*
No.of Devices or Equivalent
No.of Water 1 Kw No.of .of Ba a g Data Wiring:
Heaters Siens No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total H� Telecommunications Wiring:
No.of Devices or Eauivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to start: Inspection 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 0 BOND 0 OTHER 0 (Specify:)
I certify,under the pains and penalties of perjuty,that the information on this application is true and complete.
FIRM NAME: E F WINSLOW PLUMBING HEATING CO INC
Licensee: RICH M MELVIN Signature LIC.NO.: 21829
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address:8 REARDON CIRCLE, SOUTH YARMOUTH MA 02664 Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License:
OWNER'S INSURANCE WAIVER:I am aware that the License does not have the liability insurance coverage normally required by law.But my
signature below,I hereby waive this requirement.I am the(check one) 0 owner 0 owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $50.00
Commonwealth of Massachusetts FOfficial Use Only 7
s �I= �
1 S t Permit No. t✓22�2"1c (
„I- 7" Department of Fire Services
11=s 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 ALL INFORMATION) Date: 10/19/2021
City or Town of: YARMOUTH(SOUTH) To the Inspector of Wires:
QBy this application the undersigned gives notice of his or her intention to perform the electrical work described below.
u ) Location(Street&Number)11 CROSBY ST.
103- Owner or Tenant LARRY PINCUS Telephone No. 6176454282
Owner's Address SAME
Is this permit in conjunction with a building permit? Yes El No El (Check Appropriate Box)
t^ — Purpose of Building UtilityAuthorization No.
Existing Service Amps / Volts Overhead 0 Undgrd El No.of Meters
�" New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
U.1 Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: BOILER/WATER HEATER
Completion of the following table may be waived by the Inspector of Wires.
Total
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.ofKVA
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above In- No.of Emergency Lighting
grnd. ❑ grnd. ❑ Battery Units
00 No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
(
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
I4 No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
P Totals: Detection/Alerting Devices
A'". No.of Dishwashers Space/Area HeatingKW Local Municipal ❑Other
P ❑Connection
No.of'Dryers Heating Appliances KW Security Systems:*
rY No.of Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW Signs Ballasts No.of Devices or Equivalent
-No-H dromassa Bathtubs No.of Motors Total HP TelecommunicationsNofDeiDevices
or Equivalent
QO Y ge No.of Devices Equivalent
i` OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
iPir Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 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 ® BOND 0 OTHER ❑ (Specify:) .
I certify,under the pains and penalties ofperJury,that the information on this ap licatlon is true and complete.
FIRM NAME: E.F. WINSLOW PLUMBING &HEATING CO., I LIC.NO.:3281C
Licensee: RICHARD MELVIN Signature LIC.NO.:21829A
(If applicable,enter "exempt"in the license number line.) Bus.Tel.No.:508-394-7778
Address: 8 REARDON CIRCLE SOUTH YARMOUTH,MA 02664 Alt.Tel.No.:
*Security System Contractor License required for this work;if applicable,enter the license number here:
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)El owner n owner's agent.
Owner/Agent I PERMIT FEE: $
Signature Telephone No.
E.F.Winslow Inspection Department email : inspections@efwinslow.com
The Commonwealth of Massachusetts
a Department of Industrial Accidents •
•
9_—=,t-,,.,,,,, Office of Investigations
1, ==t = Lafayette City Center
Cs�_ `= 2 Avenue de Lafayette, Boston, MA 02111-1750* �•'' wwx.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: E.F. WINSLOW PLUMBING & HEATING CO, INC.
Address: 8 REARDON CIRCLE
City/State/Zip: SOUTH YARMOUTH, MA 02664 Phone #: 508-394-7778
Are you an employer? Check the appropriate box: I I Business Type(required):
1.❑■ I am a employer with 90 employees (full and/ 5. 0 Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]** 11.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.1=1 Other
*My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. #1964A Expiration Date:01/01/2022
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under § 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of
the DIA for insurance coverage verification.
I do hereby ce •
the ins/and penalties of perjury that the information provided above is true and correct
Signature: ).-//` -'!'--- Date: 01/02/2021
Phone#: 508-394-7778
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(check one):
1.❑Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board
5.0 Selectmen's Office 6.❑Other
Contact Person: Phone#:
www.mass.gov/dia