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EP-90747
TOWN OF DARTMOUTH -:BUILDING DEPARTMENT RECEIPT 90747 ket PHONE: 508-910-1820 FAX: 508=910.1838. , Namti6t2r-t .. CDT).(1ii (' ti id,r'(\hiPropertyOwner. F' / 11{I ' Oct' "DatI1/2O// Job Location: j( '-,�l OI k.I if i, ;y Map: Gr (0 Lot: �i-Ci et--- Description General Ledger#'s Ref. # Amount Building & Building Misc. ,\-‘01811 cri 4105 Electrical t 901000-44116 %Q frr, 7 S e Plumbing & Gas 0. eYOf 4410t Trench Safety 01 Q)0-444-.9 K 1® Other Department Revenue y-giohl 420 a ENTS ,( ,, ?(JL. White-Collec[or's Officc Yellow Copy-Customer's Receipt Pink Copy epT ER eee N B �J" THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS • ,.. • fl Official Use Only ��I � C ommonruaaC[[ 7 t�o� !/e9dec�iudelbl --.' - - c7 Pemai t o. —y. 2apartmenf of 2ire Serviced - 1 .. 0 upancy and Fee Checke BOARD OF FIRE PREVENTION REGULATION' 1 v. 11/99j (leave:blank) • tztb FOR PERMIT TO PERFORM! ELECT! ICAL WORK \)/ All work to be performed in accordance with the Massachusetts Electrical Code(MEC),SZ7 CAIR 12.00 (PLEASE PRINT/N INK OR TYPE ALL INFORMATION) . Date: \ It I )54 I K I City or Town of: ` or-±h OVk'*l To the Inspector of Wires: �t��l By this application the undersigned givesgi"notice of his or her intention to perform the electrical!'•ork described below. I11Y1 Location(Street&Number)3 vU'd'"�1Y1 cih Dr �1 u_yaV'xI f2 L a rnot nd-os T4lephane,o. Owner or Tenant 7 Owner's Address 3 et:A d-=l nch Y g Is this permit in conjunction'with a building permit? Yes �i N Q (Ch k Appropriate Box) Purpose of Building r-es(UX�t Utility uthorizatioi'Vo. _ . .. . ___ t. Existing Service Amps / Volts Overhead ❑ tdgrd E . Nu.oC lIctcrs New Service Amps / Volts Overhead ❑ Ulf and J No.of Meters it Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: jnS 11 Qn C� �J WO.v`/1()vh-Icrt . scotch KXAY\-IS I0%F<SKW) Completion of the following table maybe waived by the Insocctnr of:Vines. No.of Torsi No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans I"transformers I<VA No. of Lighting No.of Hot Tubs Generators KVA Outlets Above 1n_ No.olhergencv Lighting No. of Lighting Fixtures !Swimming Pool crud. ❑ grad. ❑ 'Batter'mUnits l No.of Receptacle Outlets No.of Oil Burners IFIREALA>RMS No. of Zones No.of Detection and lNo. of Switches INo.of Gas Burners I Initiating,D evi ces Total lNo.of Alerting Devices No. of Ranges No.or Air Cond. Tons cleat Pump Number !.Tons IKW No.of Self-Contained No. of Waste Disposers Totals: i Detection/Alerting Devices Municipal No. of Dishwashers SpacdArea Heating I•CFV Local ❑ Connection ❑ Other No.of Dryers KW!Heating Appliances r Security Systems: No.of Devices or Equivalent No. of Water No.of No.of Data Wiring: Heaters • KW Siatis Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydronmssage Bathtubs No.of Motors Total HPIo.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the perfomiance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent_ The . undersigned cerflfies that such coy rage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE g BOND ❑/f�OTHER 0 (Specify.) —...,-- (Expiration Dat } Estimated Value of Electrical Work: [ 3, v ' (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under the pains and penalties ofperj+rq',that tthe information on rids application is true and complete. AI �12A\f4 1� 1CditCmrt. - LIC.NO.:r¢ I as FIRM NAME: // y M �'C//q Signature 7� iO'� LIC.NO.: F.3&� g Licensee:c: en ' i r mi a in fl 96a 6 (I f q enter t.qe s in the lifel number linaf Bus.Tel.No.: 5,y—7 Address: I Sf'AGPtn4ch r4 Lfr'rsr nl"j' ✓MA Oa790 Alt.Tel.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,1 hereby waive this requirement. I am the(check one)0 owner ❑ owner's agent. Owner/Agent Trienhone No. __I PERMIT FEE: S The Commonwealth of Massachusetts Department of Industrial Accidents n—G a/ Office of Investigations s _ 'e ' 600 Washington Street rf y Boston, MA 02111 ,;' +* www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / t J r- Please Print Legibly Name (Btusiness!Organization/Individual): .'v t j 0\QCV V t e tV c C`e c \-{ C.-:u A Address: ‘ Si-o,y+'c o at\ v- a• City/State/Zip: LAI est rar t Al A 0975o Phone#: 50 Te,a -(, 267 Are you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction mpioyees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in anycapacity. employees and have workers' P ty. 9. 0 Building addition [No workers'comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11.❑Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. +Homeowners 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. lithe sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that Lc providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: 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 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 the pains and penalties of perjury that the information provided above is true and correct Signature: P � �'��' Date: /tide/�6 Phone#: foe- 962 -6o2.67 / 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#: VIEIR-8 OP ID: DE A`C:RO CERTIFICATE OF LIABILITY INSURANCE OATE(MMI O6/26/2018) 2018 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 policy(ies)must 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 CONTACT Rua-Dumont-Audet Ins.Agcy.In NAME: 155 North Main Street (MCNNo,Ex* (A/C,No): Fall River,MA 02722 E-MAIL Jason M.Rua,LIA,CIC,AAI ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC INSURER A:NGM Insurance Company 14788 INSURED Michael Vieira INSURER B: dba Michael Vieira Electrician 1 Stagecoach Road INSURER C: Westport,MA 02790 INSURER D: INSURER E: 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 ADOL pun POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR IWVD POLICY NUMBER /MMIDD/YYYYI (MM/DDNYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LABILITY MPT0175M 11/20/2017 11/20/2018 DAMGSOERa EeNcc fmDe $ 500,000 CLAIMS-MADE I X I OCCUR MED EXP(My one person) $ 10,000 X Business Owners PERSONALS ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GGEEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 A'POLICY El 7Fff []LOG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED - SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS _ AUTOS (PER ACCIDENT) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORV LIMITS ER , ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ ' OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ I/yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Subject to actual policies' terms, conditions, definitions, coverages & exclusions. 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 C9aA4 ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD