EP-7983 TOWN OF.� DARTMOUTH v t2449
BUILDING RECEIPTS
COLLECTOR'S OFFICE
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Nam e: f ( � Property // Date: �_
l ,l t..v „Z. 1 ', 1 t ��.,�:,.� 'iOwner: L.L�,...1- .. 1 ) J -7
Job Location: - f j 'i ' i, 1 il f
( 1 White Copy.-Collectors Office
Plot: ; , / - Lot: ,,- ,. ` l `� Yellow Copy-Customer's Receipt:
1y CI: �" t Tf1WN�i i1�RTM(111TH Pink Copy-File Copy
COLLECTOR'S OFFICE Green Copy-Building Department
Phone:
,SFP 3 1999 C'
Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105 •+ F G p";'r
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106 1 L l
iJ Li- -1. J Li)t: 1 /�.) . 'v 0
r
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420
This is not a Permit or License for Building,Plumbing or Gas Received By: � .
6 / `/
The Commonwealth of Massachusetts ��
1 _.mi 1, (fie Department of Industrial Accidents
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l� =mil 3 011lesoflalrestigatoos
_ _
600 Washington Street
�. iz�y Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
:vim Ircili .ur fii:;;,r3i fi/iwe-i c�..sW. ,.I.L" .r ? "Idt;ki.:1IJ 4I a`tl El(-dliit ., ..____.......,-_.... . ... . . .
name: csi2 4UIJC I C,
location: /31 den cK6 -1- .� 7
cl• i ho.7 I/ cc V'E'r fit_ nhone# ei ? 7 ..)<--
I am a homeowner performing all work myself.
• I am a sole proprietor and have no one working in any capacity
a
• I am an employer providing workers' compensation for my employees working on this job.
comnanv name:
address:
city: phone#:
w insurance co. oolicv#
• I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
cornflour name:
atj Ir_ess:
city: phone#:
insurance co. - policy#- -
company name:
Address: - -
. city: phone#:
jnsuranee co:. - .volley# -
Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to 51500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
l do hereby cent), \/n under the pains and penalties of perjury that the information provided above is true and correct
Signature �. J f_.r—_•/2---- �- e a __�. Date
Print name sk j ii 0o��gin_ Phone#
official use only do not write in this area to be completed by city or town official
city or town: permit license# Building Department
['Licensing Board
°Selectmen's Office
°check if immediate response is required
°Health Deparbnent
contact person: phone#: DOther —
(revised 3/95 PIA)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
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 more of
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 house
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 have
been presented to the contracting authority.
Applicants
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 provided a space 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. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office 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.
.','rif•C ' 'i.r>r, e Ap
The Department's address. teien!,c^.e and R a_ .._. — ._
'hlc-Coar:t2........3it
Dcuart£tir n cS t.atiu::et_'2! Pscc:'..z :-:1
Mice of investigations
600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375
COMMONWEALTH OF MASSACHUSETTS
DIVISION OF REGISTRATION
OF ELECTRICIANS •
EGISTERED MASTER ELECTRICIAN
ISSUES THIS LICENSE TO
SOUTHERN MASS ELECTRIC
STEVEN GOUVEIA
131 JENCKS N
FALL RIVER MA 02723-2137 Y;
12747 A 07/31/01 740360
LICENSE NO. EXPIRATION DATE SERIAL NO•
COMMONWEALTH OF MASSACHUSETTS
DIVISION OF REGISTRATION.
OF ELECTRICIANS
AS A REG JOURNEYMAN ELECTRICIAN,
ISSUES THIS LICENSE TO
STEVEN GOUVEIA
171
131 JENCKS ST
FALL RIVER MA 02723-2137
31104 E 07/31/01 740359
LICENSE NO` EXPIRATION DATE.: ".SERIAL NO
•
TOWN QF DARTMOUTH 07983
BUILDING RECEIPTS
COLLECTOR'S OFFICE
Name:/{} / r i r. r - -Property .'/� Date // ( }/
L:k' LL _ \._. C u �tt-.L.L-L' Owner:. �_`..l s .i-Di _ /-/ I r o
Job Location: 1 � q ( � i ;
�. �lV�.(��J�=,.JZ �, Ljr _Li
1 White Copy-Collector's Office
Plot: / .! Lot: i.. / - Yellow Copy-Customer's Receipt
l� ,� —11 L� PinkCopy-FileCopy
Green Copy-Building Department
Phone:
Description General Ledger#'s TI O#OARTMOtiftt Amount
COLLECTOR'S °MC/
License&Permits-Building 01000-44105
License&Permits Building Misc. 01000-44105 sF P kA 1993
License&Permits-Electrical 01000-44106 v .; r j Cr)
License&Permits-Plumbing&Gas 01000-44107 S A S 03
Other Department Revenue 01000-42420 /n
This is not a Permit or License for Building.Plumbing or Gas Received By: -{ l , ), , L-L --.-✓" ft L
-t------ _ The Commonwealth of Massachusetts Pit No. V~
Occupancy&Fee Checked
0— `V. -1 -El (leave blank)
Department of Public Safety
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 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 1 '12- /�3 E3
The undersigned applies for a permit7 to perform the electrical work described below.
/ b Location (Street&Number) c V W /�
Owner or Tenant '�eU en 9- G Ina CrOC ))f TP 1 a .(�
Owner's Address 13 v L ex,c K g �- au IY C(J'L' r
Is this permit in conjunction with a building permit: Yes LSd"No ❑ (Check Appropriate Box)
Purpose of Building OGOe.k k l oQ Utility Authorization No.
Existing Service Amps—._/_Volts Overhead 0 Undgrd ^❑ No. of Meters
New Service Amps_ 1._2__ )Volts Overhead ❑ Undgrd L?l No. of Meters
1
Number of Feeders and Ampacity •
Loc .lion 4nd Nature of Proposed Electrical Work t"y I `e �P� s'1 H o m P
No. of Lighting Outlets No. of Hot Tubs No. of Transformers
KVA
No. of Lighting Fixtures Swimming Pool v.e ❑ rnd. ❑ 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
Ranges No. of Air Cond. Total No. of Detection and
No. of �.
Tons Initiating Devices Jr Heat Total Total
No. of Disposals No. of Pumps Tons KW No. of Sounding Devices
il No. of Dishwashers Space/Area Heating KW No.Dof Self Contained
etection/Sounding Devices
No. of Dryers Heating Devices KW Local ❑ Corm non ❑ Other
t No. of No. of Low Voltage
No. of Water Heaters KW Signs Ballasts Wiring
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
•
INSURANCE COVERAGE: Pursuant to the requirements of Massarhusetts General Laws
I have a current Liability Insurance PolicyPolicy_includirig Completed Operations Coverage or its substantial equivalent. YES 0 NO 0 I hay- subnt
valid proof of same to this office. YES NO 0 If you have checked YES,please indicate the type of coverage by checking the app priate
INSURANCE 0 BOND 0 OTHER ❑ (Please Specify) — tExp • on Da:
Estimated Value of Electrical Work$ .—
Work to Start Inspection Date Requested: Rough_ -inal
Signed under the penalties of perjury:
FIRM NAME S V<I'k 9—= q LIC. NO. 112 7417
Licensee (Pe 1 kg/Tatum LAC. NO. i l G 1 f
Bus. Tel. No.
Address ) 3 t Te14—K 4, Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as require:
Massachusetts/� General Laws, and that my nature on this permit application waives this requirement. Owner Agent (Pease the k one}
.( --R- r / or "e^ Telephone AIo. 1�e�117 PERMIT FEE $ "/ °
f mmature of Owner gent)
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