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EP-29084 :a v 2113 i :,' 2 l l 32 COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE OF ELECTRICIANS REGISTERED MASTER N ISSUES THIS LICENSE TO STEVEN GOUVE.IA 2 WARBLER WAY ' DARTMOUTH _ MA 02747-5310 17244 A 07/31/04 • �_ LI CENSE NO. - - 650905 EXPIRATION DATE SERIAL NO. COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE OF ELECTRICIANS 1. AS A REG JOU�RNE THSMANSELOECTRICIN STEVEN GOUVEIA 2 WARBLER WAY DARTMOUTH MA 02747-5310• 31104 E 07/31/04 501642 VVV ))) • LICENSE NO. EXPIRATION DATE SERIAL NO. _ - The Commonwealth of Massaschusetts Department of Industrial Accidents ✓ Office of investigations 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Applicant information: - Please PRINT Legibly k . 14• aqa . ` ;- name: location: city phone# 1127-- I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any capacity ❑ I am an employer providing workers' compensation for my employees working on this job. company name: address: city phone# insurance co. phone# ❑ I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation policies: company name: address: city phone# - insurance co. phone# r � sa s:: �'t-.' ® � ti � Ci slay. company name: address: city phone# insurance co. phone# 7:11Attach additional sheet if necessary ° _ * tt'at : x rs Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 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. I do hereby cert f under the pains and penalties of perjury that the information provided above is true and correct Signature: t- _Date c5: 27 '65� Print Name:Sfe(>'en (�'C U L I Ct Phone#..S&/ �6 `57%, 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 ❑ check if immediate response is required 0 Selectmen's Office ❑Health Department contact person: phone#: 0 Other Information and lnstrucnons • Massachusetts General Laws chapter I52 section 25 requires all employers to provide workers' compensation for'vheir emoiov ees. As quoted from the Flaw", 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, oranytwo or more the foregoing engaged in a joint enterprise. and includirg 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 d«:eiling house of another who employs persons to do maintenance, construction or repair work on such dwelling hous or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. NIGL chapter 152 section :5 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. Additional ly. 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 hr been presented to the contracting authority. Applicants • Please :ill in the workers' compensation affidavit completely, by checking the box that applies to your situation and suppk ing company names. address and phone numbers as ail 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 he 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. • _ 4�r • Cin. 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 till out in the event the Office of Investigations has to contact you regarding the applicant. Plea be sure to till in the permit/license number which will be used as a reference number. The affidavits may be returned t 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 question please do not hesitate to give us a call. -- — The 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 n: (617) 727-7749 • phone #: (617) 727-4900 ext. 406, 409 or 375 TOWN OF DAUTH \ 94 BUILDING RECEIPTS - COLLECTOR'S OFFICE r / / Name: `L v �f( r Property �Ci'G;-l�_�' Date ?� /elf l Owner: t Job Location- Cv)�vJ LC"t `-- 'L UC-4,. 1. / white Copy-Collector's Office Plot 1 Lot Yellow Copy-Customers Receipt D (d i Pink Copy-File Copy Green Copy-Building Department Phone Description General Ledger#'s 'Ret:# Amount License&Permits-Building 01000-44105 Z g 2003 License&Permits-Building Misc. 01000-44105 �i Qy License&Permits-Electrical 01000-44106 zoo j j License&Permits-Plumbing&Gas 01000-44107 <7 0 ) Other Department Revenue 01000-42420 ' -' This is not a Permit or License for Building.Plumbing or Gas Received By: 1.1 _-"-* ConzmonweaLMof{/rtamacAeudells Official Use Only '- Permit No. Jiapartmenl o/.cc77 ire&mecca ' BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ' 'Town of Dartmouth [Rev. 11/99] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dates q 0 3 By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) a COlAI—h ler Owner or Tenant -f p,)-eit-I 6-00 ire/ C Telephone No. Owner's Address Is this permit in conjuriciion with a building permit? Yes I I No ri (Check Appropriate Box) Purpose of Building c&tie/it ti a Utility Autu orization No. - Existing Service cCYJ Amps 12104 c tVolts Overhead I I Undgrd Z No.of Meters New Service Amps / Volts Overhead Undgrd No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /zr,I?G ire 4fccnc PO-) J J Completion✓ ofthefollowing table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No. sf Tots( Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool grnAbae Igrndr I No.ofEmeerrgency ts Lighting No.of Receptacle Outlets No.of Oil Burners i FIRE ALARMS No.of Zones t No.of Switches No.of Gas Burners No.of Detection and Initiating Devices `r No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local Municipal Connection Other No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail ifdesired,or as required by the Inspector of Wires. INSURANCE COVERAGE:Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND OTHER (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I cert , under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: , _ LIC.NO.1-7 f/G y Licensee:_ftyen Crnuu-e/0. Signature — ^ _a a LIC.No.ft I'ja el,_I)_ (Ifapplicable, enter"exempt"in the license number line.) Bus.Tel.No.; 5"-aa , "C76<S/' Address:, . Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coveragInormally required by law. By my signature below,I hereby waive this requirement. I am the(check one) IE1-6—wner owner's agent Owner/Age Signature - -C Telephone No>SO&6,572/ PERMIT FEE: $ . 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