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EP-432 ELECTRICAL PERMIT FIELD INSPECTION Dartmouth Building Department Plat: 066 400 Slocum Road-P.O. Box 79 A/7 PI-1 Lot(s) : 2-71 North Dartmouth, MA 02747 ITr1J !'i i::: Telephone 508-999-0720 iII�j�1 Fee: $20.00 Issued Date: 2/13/96 Permit No. : 432-96 Project Location: 4 Goldfinch Drive Number Street Subdivision Name: Nearest Cross Street: Electrician: Wayne Nichols Address: P.O. Box 611, Mattapoisett, MA 02739 Contact Person Phone #: (508) 993-7210 License # A11357 Proposed Use: Residential Residential,Commercial, Industrial,etc Permit. Issued To: To Install Type of Improvement,New Construction/alteration/addition/relocate security system Ext. Cost $950.00 ROUGH 2/24/96 indicate location of work(bedrm.,bath,living rm.,garage,etc.) indicate#of outlets/fixtures Owner(s) of Record: Jose A. Rodrigues Address: P.O. Box 5125 , New Bedford, MA 02745 DATE TIME TYPE OF INSPECTION REMARKS INITIAL LNSPECI k cSA c1 6 ` \‘:\ CD,1k 0 Lg \gl°7b 1\73o FkN3E-A . ©'KC (j\; Cry ELCc •- t Cad/,1z -17/ Ofttcc The Commonwealth of Massachusetts " _ Only 'n� P,? Permit b. ��—�� R-.1 31- ; Department of Public Safety Q re.) - ` t Occupancy b fee Ostte � rk t BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massachusens Electrical Code.527 CMRR 12:00 (PLEASE PRINT IN INK OR TYPE ALL I'I FORHAk'ION) Date rif %6i City or Town of P4/c)/�ivl-e L To the Inspf Wires: The undersigned applies for a permit to I perform a j9 the electrical� work described below. Location (Street & Number) % C Ly t% /A/ (-,19 U /9. �--y^ e Owner or Ienant �f/ t�hYA �/�v�✓�/g �t /,')/(�-S�7L� /`/ji Owner's Addressog Id ,/ � /'� 'Zeb/A9G�, rf as/ Is this permit in conjunction with a building permit: Yes EKNo ❑ (Check Appropriate Box) Purpose of Building /j ii.71--71i//1z/G-- Utility Authorization NO. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters New Service .bps / Volts Overhead ❑ Undgrd❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 5'C:-7 4/4 /7y t/US,%C>t'). Total No. of Lighting Outlets No. of Hot Iubs No. of Transformers KVA No. of Lighting Fixtures Swiraoing Pool Above In- grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units - _ -No. of Switch Outlets - No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Ranges No. of Air Cond. tons Initiating Devices Heat Total Total No. of Disposals No. of pis Tons KW No. of Sounding Devices No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local❑MunConnectiicipalon❑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: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Lags I have a current Liability Insurance Policy including Completed Operations Coverage or,_its substantial i equivalent. YES❑ NO I have submitted valid proof of same to this office. YES L .-'1NO El I If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE EBOND ❑ OTHER❑ (Pleasea Specify) Estimated Value of Electrical Work S /S v (Expiration Date) Work to Start Inspection Date Requested: Rough ]/�e Final �' ,LL G/e ,�l Gigned u.:der the penalties of perjury: /J q II/ FIRM NAME (d✓4-y%/e --"Werra�—�- ( _qjL/? _ ITC. NO.A //f 7 li+ Licensee t-✓13- t %'ij'e A%i Cf/L'`S Signature 2 AIG. HO. le /j,G Address ft el 42 if /L �_�,>��! /Yt4,o` ,J/ Bus. Tel. No. �- 7 { cal 1� �� I✓ ✓ J Alt. Tel. No. 77v ) di / ...rill OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) ��'//ry//o/ Patter No. PERMIT FEES ''�' �`(/ - e t(Signature of P. cr or Arent) SC- 84 C. RECEIPT F,OR PERMIT. 4 ze TOWN OF DARTM]OCUTH+f €N �� ` �� -aFR}hMrTo p f} ' i Date ' .0 � ,, Received From — Owner Location t Type K(--4%y/% �j _ ��/ Amount Paid q ,1'Gf-'07:1F/� �" A i +Received By 13astern(;asualtn Insuince Compann WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE NCCI Carrier 16942 Risk I.D. # 050212R Policy No. WC P0006730 Federal I.D. # 042899914 1. The Insured/Mailing address: I I Individual ❑ Partnership WAYNE CORP Corporation or P 0 BOX 611 MATTAPOISETT, MA 02739 Other workplaces not shown above: ( 1) ARSENE STREET BUILDING #2 UNIT # 14 FAIRHAVEN . MA 02719 2. Policy Period: The policy period is from 10/19/95 to 10/19/96 12:01 A.M. Standard Time, at the insured's mailing address. 3. Coverage: A. Worker's Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Massachusetts B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident 100 000 each accident Bodily Injury by Disease 500,000 policy lin Bodily Injury by Disease 100'000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:*11 fete )6Xdh t>;tlhtXstX HAtet:Xatt MXtiiIttXAXatiU C/XNIDX®N,KWA, iy yX See Endorsement WC 20 03 06A. D. This policy includes these endorsements and schedules:'10=220 WC242, WC332, WC350, WC367, WC441. See Information Page III for other applicable endorsements. Total Estimated Annual Premium $ - 3.039 Pro Rata Premium Applicable) $ SEMI—ANNUAL Countersigned SOUTHEASTERN INS. AGENCY 662 STATE ROAD NORTH DARTMOUTH, MA 02747 C w.era° Date 08-15-95 By Authorized Repress tabus ARC: 177 .54 THIS INFORMATION PAGE WITH THE YERS LIABILITY INSURANCE POLICY • ENDORSEMENTS,IF ANY,ISSUED WORKERS FORM A PA,}T THEREOF,EOF,COMPLEON AND TES THE ABOVE NUMBERED POLICY. _.__ IMRUAFD DOPY ' k WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE P (Ed. 4-84) Policy Number: EXTENSION OF INFORMATION PAGE OLICY WCP0006730 4. Premium: The premium for this policy will be determined byWAYNE CORP our Manuals of Rules, Classification, Rates and Rating Plans. All information required below is subject to verification and change b Classifications 9 y audit. Code Premium Basis No. Total Estimated Rate Per Estimatede Annual ELECTRICAL WIRING Annual Remuneration $1o�of TELEPH CO: Remuneration Premiums CLERICAL OFFICE EMPLOYEES 5190 26,500 7600 27>300 3.71i I >776 904 SALESMEN MSSRG5 5310 3.3.1 COVERAGE COLLCTRSEMPLOYERS 8742 16>$00 0.30 190 MERIT RATING — LIABILITY ., 9$45 30>200 O•b3 50 0.05 Y. 190 STANDARD PREMIUM SUBJECT TO DI ' 0 EXPENSE CONSTANT —146 DIA ASSESSMENT 3, 05'00 2,774 a% OF STANDAR+ PREMI M . 160 105 r7 7inimum Premium $ 445 Total Estimated Annual Premium: $ 3,039 Pro-Rata Premium (if applicable): $ SEMI—ANNUAL