BLDE-23-001404 Commonwealth of Official Use Only
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Massachusetts
Permit No. BLDE-23-001404
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 IN INK OR TYPE ALL INFORMATION) Date:9/16/2022
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) 4 OAK GLEN VILLAGE
Owner or Tenant GALLAGHER MARLIS C TR Telephone No.
Owner's Address THE GALLAGHER TRUST,4 OAK GLEN VILLAGE,YARMOUTH PORT, MA 02675
Is this permit in conjunction with a building permit? Yes 0 No ❑ (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: Install air conditioner(Replacement)
•
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting
rnd. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiatine Devices
No.of Ranges No.of Air Cond. 1 Ton l No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: Detection/Alertine Devices
No.of Dishwashers Space/Area Heating KW Local 0 Municipal 0 Other:
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Ballasts Data Wiring:
Heaters Siens No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
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 perjury,that the information on this application is true and complete.
FIRM NAME: ANDREW M LEVESQUE
Licensee: Andrew M Levesque Signature LIC.NO.: 17318
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address:461 LOWER COUNTY RD, HARWICH PORT MA 026461831 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: $130.00
J- 1(1/7-?'
14 Comnanweanh o j Plaesacivaalto OfficialUse Onl
'' kt ,/ Permit No. � 'Z,--A 4
2eparbmsnl of ire Serviced
' Occupancy and Fee Checked
_ - BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
1�S All work to be performed in accordance with the Massachusetts Electrical (MEC),527 CMR 12.00
3 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: `! '3/24 o?-D—
City or Town of: '1�{�V 1 C U "H To the Inspector of Wires:
y By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
--_ Location(Street&Number) i-{- OA G(-N
`J Owner or Tenant ( i A(' �- Telephone No.
.� Owner's Address
_ C'. Is this permit in conjunction with a building permit? Yes ❑ No 0, (Check Appropriate Box)
Purpose of Building a s4 9- N C Utility Authorization No.
Existing Service Amps / Volts Overhead 0 Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd 0 No.of Meters
Number of Feeders and Ampacity
---14. Location and Nature of Proposed Electrical Work: tAl He I N& lo (ew\i'r A jG
44
kri Completion of thefollowingtab/e my be waived by the lncfor of Wires.
Total
L Tr aan No.of Recessed Luminaires No.of CeIL-Suep.(Paddle)Fans Trf KVAsformers KVA
. No.of Luminaire Outlets No.of Hot Tubs Generators KVA
j No.of Luminaires Swimming Pool Above ❑ In- ❑ Pro.or emergency Lighting
tcrnd. grid. "I Battery Units
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
1..' No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons __�KW"_ No.of Self-Contained
Totals: ""' Detection/Ale i Devices
No.of Dishwashers Space/Area Heating KW Local 0 Monnectionuni"1 0 Other
C
No.of Dryers Heating Appliances KW "Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Whine:
No.of Devices or Equivalent
OTHER:
Attach additional detail ifdesirea or as required by the Inspector of Wires.
Estimated Value of 1 'cal Work: ( T) - (When required by municipal policy.)
Work to Start: 6;1 14- 2027- Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE CO RAGE: 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 tg BOND 0 OTHER 0 (Specify:)
I certify,under the pains and penalties of perjury,that the Information on this application is true and complete
FIRM NAME:4{'fkfew 1(A-S`PORf - ATIW&-t— CODUN$ LIC.NO.: 17
Licensee: ((A4-01 LIE VC5Ql.it Signature IC.NO.:
(Ifapplkabl enter"exempt"in the license number line.) " s.-Tel.No..
Address: 4 I IANIVEK N'(A4 W 4.1-. IAI I&o r0 VW oV "Alt.TeL No.:
*Per M.G.L.c. 147,s.57-61,security workrequires Department of Public Safety"S"License: Lic.No.
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
Signature Telephone No. PERMIT FEE:$ 5'Q,-
, - , The Commonwealth of Massachusetts
Department of Industrial Accidents
9Office of Investigations
I , i,' Lafayette City Center
J t,J 2 Avenue de Lafayette, Boston,MA 02111-1750
'1; -'-''% www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):Harwich Port Heating &Cooling, LLC.
Address:461 Lower County Road
City/State/Zip:Harwich Port MA 02646 Phone#:508-432-3959
Are you an employer? Check the appropriate box: Type of project(required):
1.0 I am a employer with 70 4. 0 I am a general contractor and I 6 0 New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9. ®Building addition
[No workers' comp.insurance comp. insurance.$
required.]
5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 110 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.® Other HVAC
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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:Selective Insurance Company
Policy#or Self-ins. Lic.#:WC9059813 Expiration Date:1 0/26/2022
Job Site Address: Lf C- -k 6 N City/State/Zip: i M- v1`�" re-PT
Attach a copy of the workers' compensation policy declaration page(showing the policy nutfnber and expiration date).
Failure to secure coverage as required under Section 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 certify under a ins and p /rallies of perjury that the information provided above is true and correct.
Date: 631 I ( )2— --
Signature:
Phone#: 508-432-3959
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):
10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5E'lumbing
Inspector 6.0Other
Contact Person: Phone#: