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EP-166 E LE CTR ICAL PE RMIT FIELD INSPECTION Dartmouth Building Department Plat: 066 400 Slocum Road-P.O. Box 79399 Lot(s) : 2-78 North Dartmouth, MA 02747 Telephone 508-999-0720 . 101?2 Fee: $80.00 Issued Date: 09/18/95 Permit No. : 166-95 Project Location: 25 Goldfinch Drive r, Number Street Subdivision Name: eep Nearest Cross Street: Electrician: Joseph Benton Address: 75 Flagg Street, Bridgewater, MA 02324 Contact Person Phone #: (508) 947-4856 License # 2182SE Proposed Use: Residential Residential,Commercial, Industrial,etc. Permit Issued To: Complete wiring new dwelling Type of Improvement.New Construction/alteration/addition/relocate New service 150 amps, 240/120 volts, underground, 1 meter, 3 - 2/0 Tri, 12 lght out. , 12 lght fix. , 100 recpt out. , 18 swth out. , 1 range, 1 dishwasher, 1 dryer, 1 oil burner, 1 fire alarm, 3 det dev. , 3 sound dev. , Est. Cost $2, 000 ROUGH SEPT 19, 1995 indicate location of work(bedrm., bath, living rm.,gma$e,etc.) indicate#of outlets/fixtures Owner(s) of Record: Kim & Doug Rogers Address: 6 Norwell Street, South Dartmouth, MA 02748 DATE TIME TYPE OF INSPECTION REMARKS = INITIAL 01111111 INSPEC. ,0\D �‘-3 , v1 C to S \ o "cc& T Svoip.N40 - �flv. - 10-q - 111/11111 nen 4• 5 `i/ ;Wan. Fri: 9. .t Office Use Only • • The Commonwealth of Massachusetts Permit No. •G Y Occupancy&Fee Checked ww J-0 �71 (leave blank) Department of Public Safety lc/c-4 s — BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK Town of Dartmouth All work to be performed in accordance with the Massachusetts Electrical Code. 527 CM 12:00 ,,. (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date a /PI 9v The undersigned applies for a permit to perform the electric work descri/bed below. I�t // Location (Street&Number) Cif (r'il ,S/eac�f nn e0 4 /.-j ' 2 6 ��' � '® / Owner or Tenant �/ frrl P,Per-t y— �ei' S Owner's Address <J e��ff i // Is this permit in conjunction with a building pe Yes NLJ o ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service .A //ymps / Volts Overhead ❑ Undgrd E No. of Meters New Service A f✓Amps /is o Volts OverheadZ ❑ Undgrd ''- /`' No. of Meters I' Number of Feeders and Ampacity ✓ — � i S 'J'/ Location and Nature of Proposed Electrical Work IV Mi# ji2��`A--- G'� +} No. of Lighting Outlets / No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures /2, swimming Pool oiled Generators KVA No. of Receptacle Outlets / /1 C) No. of Oil Burners No.e f Emergency Lighting Lf Battery No. of Switch Outlets /SO No. of Gas Burners FIRE ALARMS NO. of Zones No. of Ranges No. of Air Cond. Total No. of Detection and Tons Initiating Devices C f No. of Dis osals No. of Heat Total Total No. of Soundin Devices P Pumps Tons KW g No. of Dishwashers PHeating S ace/Area KW No. of Self Contained Detection/Sounding Devices No. of DryersHeatingDevices KW ❑ Municipal n' / Local Connection ri Other No. of Water Heaters KW No. of No. of Low Voltage Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: yr INSURANCE COVERAGE: Pursuant to the r irements of Massachusetts General Laws I have a current Liability Insurance Polic di�n$$Completed Operations Coverage or its substantial equivalent. YES NO ❑ I have submitted valid proof of same a to ice. YES NO L i If you have checked YES,please in 'cate the type of coverage by checking the appropriate box. INSURANCE L/d'BOND E OTHER ❑ (Please Specify) - le-01 ? (hxpuauoli at`l Estimated Value of Electrical Work$.,2A�)Q j /� r Work to Start Inspection Date Requested: Rough cf.; Final Signed under the penalties of perjury: �y FIRM NAME J suet/ 2 �'fGrt LIC. NO.i -�= Licensee Signature LIC. NO. ,�) �+ y,� Bus. Tel. ar.2 11 Address �� o / AU- 1�/flGJP�/ 1/o//l• Alt. Tel. No. ��iiL- OWNER'S INSURANCE WAIVER: I am aware that the vale) does not have the insurance coverage or its substantial equivalent as required b, Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. ' PERMIT FEE $ (Signature of Owner or Agent) r RECEIPT FOR PERMIT o r TOWN OF DARTMOUTH ✓44 -f C-N PERMIT NO. Date 2 'f ' 7 o Received From --it-4274: S2 wt,.. \ -A� eOw /�ner Vti a - ration - f -� iwtP Type e.,,,-4-'tt--61.'2-' Amount Paid U - I' ale' Received By _r . /.1/ L The Commonwealth of Massachusetts Department of Industrial Accidents _72 Officeofln ga#oas -. 600 Washington Street % _'!'7 Boston,Mass. 02111 Workers' Compensation Insurance Affidavit t contrail a atttnr .:_ _-..-_ . :a:. _ . `1N1`. zr:.---•�:; s..r : _ r7 � � 04 A name. ell 92-1 location: n �j�..,{� rwcr /� /nE / city � /f/ / 1 nhon CiN C"" `yJJb f am a homeowner perf tmmg all work myself. ei am a sole proprietor and have no one working in any capacity - E I am an employer providing workers' compensation for my employees working on this job. company name: - - address: rim nbene.#: : insurance co. noHey#: E I am a sole proprietor. general contractor, or homeowner(ca:[e one)and have hued the contractors listed below who h the following workers' compensation polices: company name: address: cif nhone#i - - insurance co. -oilier#- - - company name: - -- address: cin•: phone#: insurance co. Attachadditionais�eetffaeeemn- --•==r;--� - Failure to secure coverage as required under Section 25A of JMGL 152 can lead to the imposition of criminal penalties of a fine up to 51_500.00 and.' one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of5100.00 a day against me. I understand that copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby cerrif} under ains and penalties of perj that the information provided above it byte and correct Signature p lealb.,//1/ � �� of Date e /7e1 /S�/ Print name �,t D .Cep% _gen /'/JYl Phtme# 3©OP77 2— A-Cet l r official use only do nor write in this area to be completed by city or town official ` ciny or town: permit/litease# fBuilding Department ❑Licensing Board check if immediate response is required OSelectmen's Office pHeaftb Department contact person: - phoned; °Other Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for the:: employees. As quoted from the "law", an employee is defined as even person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association. corporation or other legal entity, or any two or more the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer. or the receiver or trustee of an individual , partnership, association or other legal entity', employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance . construction or repair work on such dwelling hou. or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter ha been presented to the contracting authority. tppiicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has providedaspace at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pleas be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned tc the Department by mail or FAX unless other arrangements have been made. The Offi_a of Investigations would like to thank you in advance for you cooperation and should you have any questions please do not hesitate to give us a call. YR Department's address, telephone and fax number:: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston. Ma. 02111 fax #: (617) 72-7749 phone #: (617) 727-4900 ext. 406. 409 or 375