EP-331 ELECTRICAL PERMII
FIELDL INSPECTION
400DartSlocumBRoad-P.O. Boxng t�f' i�- = 1j 1,E�(�D Lot(s) : 02-82
North Dartmouth, MA 02747
Telephone 508-999-0720 Fee: $80.00
Issued Date: 12/06/95 Permit No. : 331-95
Project Location: 3 Goldfinch Drive
Number Street
Subdivision Name:
Nearest Cross Street:
Electrician: Joseph Benton
Address: 75 Flagg Street, Bridgewater, MA 02324
Contact Person Phone #: (508 ) 947-4856
License # 21825E
Proposed Use: Residential
Residential,Commercial, Industrial,etc.
Permit Issued To: Wiring New Dwelling
Type of Improvement;New Construction/alteration/addition/relocate
New service 150 amps, 240/120 volts, underground, 1 meter, 15 lght out. ,
15 lght fix. , 40 recpt out. , 10 switch out. , 1 dishwasher, 1 dryer,
1 oil burner, 4 sound dev. , 4 det. sound. dev. , ROUGH DEC 7 , 1995
indicate location of work(bedrm.,bath,living rm.,garage,etc.) indicate#of outlets/fixtures
Owner(s) of Record: Alex Fernandes
Address: P.O. Box 776, Westport, MA 02790
DATE TIME TYPE OF INSPECTION REMARKS INITIAL ':'
INSPEC. ,
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i p-1$kc- k O 3 O 12-Q
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Office Use Only
_ The Commonwealth of Massachusetts Permit No. 33/- 9 S- J
+_•= Occupancy&Fee Checked O ��
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-_ � Department of Public Safety (leave blank��_�, �
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BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 , k�
ED
APPLICATION FOR PERMIT .TO PERFORM ELECTRICAL WORK
wit o D rt nb Cth
All work to be performed in accordance with the Massachusetts Electrical Code. 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date c4), 6
The undersigned applies for a permit`�to performm a the electrrii9alwork dgscribed below.. n
c�Location (Street& Number) 0 7C L /c/Iva `120��e_
�Owner or Tenant /e /C. 'Xn' /D4 /
Owner's Address
Is this permit in conjunction with a building pe jt,: ‘,� Yes - No ❑ (Check Appropriate Box)
Purpose of Building ,VC �./ Utility Authorization No. _
Existing Service _Amps_/ Volts Overhead ❑ Undgrd ❑ No. of Meters
New ServiceAmps_ / /.aQVolts Overhead n Undgrd _ No. of Meters
Number of Feeders and Ampacity �(�V� A 4
Location and Nature of Proposed Electrical Work l .)7 AI &C.&
No. of Lighting Outlets /r No. of Hot Tubs No. of Transformers Total
KVA
No. of Lighting Fixtures / (5--_ Swimming Pool K ave ❑ nd ❑ Generators KVA
No. of Receptacle Outlets yr® No. of Oil Burners / No. of Emergency Lighting
Battery Units
No. of Switch Outlets /® No. of Gas Burners FIRE ALARMS NO. of Zones
No. of Ranges Total No. of Detection and
g No. of Air Cond. Tons Initiating Devices
To
No. of Disposals No. of Pumps Tons KWl No. of Sounding Devices /
No. of Dishwashers / Space/Area Heating KW No. of Self Contained �/
Detection/Sounding Devices fr`
No. of Dryers / Heating Devices KW Local ❑ Monnectunicipalion n Other
C
No. of Water Heaters KW No. of No. of Low Voltage
Signs Ballasts Wiring
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
Y
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws �NO/❑ ^
I have a current Liability Insurance Polic inCompleted Operations Coverage or its substantial equivalent. YESs I have submitted
valid proof of same to office. YES NO If you have checked YES,please indicate the type of c verage by checking the ap opriatee b'ox.
INSURANCE BOND ❑ OTHER ❑ (Please Specify) /.e� ��(�� 54 �9E7
( xpaatron Date)
Estimated Value of Electrical Work$ ��
Work to Start Inspection Date Requested: Rough- ,Z C / Final
Signed under the penalties of perjury:
FIRM NAME t - LIC. NO[7C/(p��<
Licensee Signature LIC. NO.
�j� �/� _ Bus. Tel. No. _9 /fL C/
Address /l� / /1'Sy/ C ` �/�f� �., Alt.Tel. No. /" L C1 -
OWNER'S INSURANCE W R: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by
Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one)
(Signature of Owner or Agent) Telephone No. PERMIT FEE $
4
RECEIPT FOR PERMIT
�re,.., TOWN OF DARTMOUTH e y rS P RMIT 6. ('
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� No Date /2
Received From !�\;;1K...-�t _ r
Owner �. .J--f,/j_... g 4 .
Location{ '
Type —v A (lI JAi /F -
Amount Paid4 i/ 0�7
Received @y x f ' /I
1...- f Lam\ I x
_ - The Commonwealth of Massachusetts
i=b Department of Industrial Accidents
T e 'e II Wee off
? `=__> ;: 600 Washington Street \,
•-‘3 Boston,Mass. 02111
a .
Workers' Compensation Insurance Affidavit
licantini att 2^'<.1. . • .. _ _ :.``
C1
ipCa::p'if 3 - �i� - 2Xt�e_
dn. )2fri—fteTh ‘t
pinny— .fl& a homeowner performing all work myself.
ka sole proprietor and have no one working in any capacity
m an employer providing workers' compensation for my employees working on this job.
company name: . . ..
addresc:
rim
Winne#•
insurance co. - -.
C I am a sole proprietor, general-(:nn'.ractdr, or homeowner(carte one) and have hired thy contractors yls ed below who h
the following workers' compensation polices:
company name:
address: -"
rim -.• nhbneitr ....
insurance co. -
noiiry
company name: •
- _
address: - -
rim
nhonesk-
•
insurance co. nohty#t:
.ltttiea addidoaai aEeti ifinerisan- =_e—•_ . . . _. e..y;, - . - _ _
Failure to secure coverage as required under Secnon 254 of 11GL 152 can lead to the imposition of criminal penalties
• f a Fine up to •
� 4os
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of5100.0 ay 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 cenifi•under the pains and penalties o • a the information provided above is tine and coma.
Sisr.anre 7 Rate /
(� le? . CW—
Print name
J 9 /7 h
..
official use only do not write in this area to be completed by city or town official -
c
,_ city or Town:
permit/littme# rtBuiiding Department t
r
[(Licensing Board c
_check if immediate response is required t
OSeiectmen's Office
contact person: phone N; [(Health Department f
rnOtber e.
•
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for
employees. As quoted from the "law", an employee is defined as every 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 m
the foregoing engaged in ajoint 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 -
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 ':
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean empio}
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 chapte:
been presented to the contracting authority.
1ppiicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation anc
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 regal:-
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 provided-a:space at the bottom
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. P
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be retnrne
the Department by mail or FAX unless other arrangements have been made.
The Off:.e of Investigations would like to thank you in advance for you cooperation and should you have any quest
please :o not hesitate to give us a call.
The Depanment'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) 727-7749
p'tone ': (617) 727-4900—3900 ext. 406. 409 or 375