EP-6010 1
1T
COMMONWEALTH OF MASSACHUSETTS
P. DEPARTMENT OF INDUSTRIAL ACCIDENTS
f 600 WASHINGTON STREET
James Camooeu BOSTON, MASSACHUSLi IS 02111
Comn-ss+one•
WORKERS' COMPENSATION INSURANCE AFFIDAVIT
I, C (1Aer 2
(licensee/perminee)
with a principal place of business/residence at
447,h 8/. j flea r l tan 726 lam? Ifl A 6,2 An
(City/Stare/Zip)
do hereby certify, under the pains and penalties of perjury, that:
[ am an employer providing the following workers' compensation coverage for my employees working on this
job.
wocaster WKX10375
Insurance Company Policy Number
[ ] I am a sole prop.ietot and have no one working for me.
[ ] I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below
who have the following workers' compensation insurance policies:
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
0 I am a homeowner performing all the work myself.
NOTE: Please be aware that while homeowners who employ persons to do maintenance,construction or repair work on a
dwelling of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto are not generally
considered to be employers under the Workers' Compensation Act(GL C. 152,see- 1(5)),application by a homeowner for a license
or permit may evidence the legal status of an employer under the Workers' Compensation Act.
I understand that a copy of this statement will be forwarded to the Department of Industrial Accidents'Office of Insurance for coverage
verification and that failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop'Work Order and a
fine of S 100.00 a day against me. /
Signed this /C *h day of i91r/'! , 19 98
Lice. see.%Permittec Licensor/Permitror
W
Tow,., 0 «neic' ;T�
NO TAX ISSUES BUILDING RECEIPTS 0601 i
COLLECTOR'S OFFICE T
Name / • �,, £ , Property it , C_ + .' Date 4�� h
i � �� Owner: :6 . . , 'L �y
Job Location: 7 / ,
iIQ i. ,-, a-_
- -- '_ White Copy-Collector's Office
Plot: / / LOU F _ Yellow Copy-Customer's Receipt
Pink Copy-Pile Copy
: Green Copy-Building Department
Phone:
/', Y
L _-
Description General Ledger#'s TOWN S(2tfAtMonm Amount
License&Permits-Building 01000-44105 COLLECTOR'S OFFICE
1
License&Permits-Building Misc. 01000-44105 APR 2 1 1R9a
License&Permits-Electrical 01000-44106 tc-1P' 9
License&Permits-Plumbing&Gas 01000-44107 ^ f 07
Other Department Revenue 01000-42420 r7
This is not a Permit or License for Building,Plumbing or Gas Received By: " ' ' ' "
r TOWN OF DARTMOUTH
BUILDING RECEIPTS1
COLLECTOR'S OFFICE
Name /i t : - Property " / r Date
-!r, 7. %. . fr - /cam
Job Location: 1 /
White Copy_Collectors Office
Plot: -> - - Lot: s _ Yellow Copy-Customer's Receipt
.. / Pink Copy-File Copy
a - Green Copy-Building Department
Phone:
Description Genera Ledger#'s TOWN(f6 #TMOUTH Amount
License&Per its Bcircdiiig ,./ 010O0-44105 Gy1LLELTUEi'S OFFICE
m
License&Permits'.-,Building Misc` .- -�---- 01000_=44105 f APR 2 1 1998
License&Permits,'Electrical ` -- fi1000-'44106 / '/ o
License&Permits-$L'l ibing&5.Grs--- ,` 01000-44 i /- C S G 07
Other Depj2tmenf Reverine '. / Of040-424-2fl/
This is not a Permit or License for-Building.Plumbing a-Gas Received By: �' s�l
/ , L/ Y Pc--;„ ,
j
Office Use Only 6 /' 76
The Commonwealth of Massachusetts Permit No.
=•=a_ / Occupancy&Fee Checked re— ire7
` Department ofPublic Safety (leave blank)
P Iy /f �dft
ff
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. p 52277 CMR 12:OQ
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (/� 5// -1 p 6
The undersigned applies for a permit to performthe electric described below. g____
Location (Street&Number) 1 1 11-�(,l )rPer""1 1~GLn.(�Q
Owner or Tenant it,
-I-- Sens-)
St.
Co r m ac S 1 /07f
Owner's Address 3 5 i(A JC u+h 1 L 1 Gt-1 1 St. ) A\K-I it`ffirn ) VI I5I n i a , M(t a.a aC e
Is this permit in conjunction with a building permit: Yes LNo L (Check Appropriate Box)
Purpose of Building S_______ _I m'f f Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Sips Amps Ito / a r2i n Volts Overhead ❑ Undgrd No. of Meters I
Number of Feeders and Ampacity (3) a /n AL �t �+
Location and Nature of Proposed Electrical Work (lQA l ) h 0 US) LA 1 1(''1 a. W/ U t CO l n , J VS ,
No. of Lighting Outlets 026 No. of IL.t Tabs No. of Transformers —j Vtal
No. of Lighting Fixtures 4 6 Swumning Puol gr dVe ❑ gmd, n Genefatoj --- KVA
No. of Receptacle Outlets e No. of Oil Burners No. of Emergency Lighting
Battery Units
No. of Switch Outlets 3 L/ No. o£-Gas_Burners FIRE ALARMS NO. of Zones
Total No. of Detection and
No. of Ranges / No. of AL Cund. Tons Initiating Devices
N,,.. eL Ei_posalc Heat Total Total
No. of Sounding Devices
S ace/Are
No. of Dishwashers p a g KW No. of Self Contained Detection/Sounding Devices
No. of Dryers Heating fe KW Municipal ❑
ry Local Connection Other
No.Signso No. st Low Voltage ±J J „ n/ a h'n l
IW. .,f Waie� Hcater� KW� No.of Wiring tC X
No. Hydro_Massagc T I_bs Nq of Motor._ ____ Total HP er nfl
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws �,,
I have a current Liability Insurance Polic,�r ding Completed Operations Coverage or its substantial equivalent. YES L`9 NO ❑ I have submitted
valid proof of saamee10 this office. YES LDS NO LJ If you have
checked YES,/please indicate the type of coverage by checking the appropriate box.
INSURANCE R BOND ❑ OTHER ❑ (Please Specify) al- k.n b h1-y y— 13 -9 R'
/ xprration ate
7 Estimated Value of Electrical Work$ 7-60 -- `` �
Work to Start 4/c2a/98 Inspection Date Requested: Rough l 1 1 @ . Final lC l It Ca Q X
Signed under the penalties of perjury:
FIRM NAME )%u_n1 `q Ct.'ecl-c- Ca ..2 rVl cos Inc e LIC. NO. /9/0833
Licensee -Rohe(T� A A . yel l n.S Signature C& 1'`'i LIC. NO. &o 9 Y6o g
-//1 n.^/ �` T aim
y��7 n Bu el. No.
Address r a.6 fit F) c SY, RPor row ai0 n I / / //"1 Alt. ' el. 4o.
OWNER'S INSURANCE(AIVER: I am aware tAiat 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 or Owner or Agent) Telephone No. PERMIT FEE $ 7�
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