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EP-328-95 ELECTRICAL PERM FIELD INSPECTION Dartmouth Building Department Plat: 76 400 Slocum Road-P.O. Box 79399 Lot(s) : 24-5 North Dartmouth, MA 02747 Telephone 508-999-0720 Fee: $20 . 00 Issued Date: 12/05/95 Permit No. : 328-95 Project Location: 19 Shingle Island Lane Number Street �. Subdivision Name: yJ Cv/ Nearest Cross Street: Electrician: Glenn Wood Address: 88 Drift Road, Westport, MA 02790 Contact Person Phone #: (508 ) 636--6605 License # 27638 Proposed Use: Residential Residential, Commercial, Industrial,etc. Permit Issued To: Additional Wiring Type of Improvement, New.Construction/alteration/addition/relocate 200 amps 115/230 volts, underground, 1 meter wiring 2nd floor Est. Cost $350 . 00 Ready indicate location of work(bedrm.,bath, living rm.,garage,etc.) indicate#of outlets/fixtures Owner(s) of Record: Gene Beaudoin Address: 19 Shingle Island Road, North Dartmouth, MA 02748 DATE TIME TYPE OF PINSPECTION REMARKS INITIAL ' INSPEC. " iz.\ e`ti 12tcLC RO\ilCA O'k �s 'Paw\sc-rj Q US rfa55,() U v \�l c-&-p- A - it 'P_k, tw +� t .tia o ie e.: -, `c',4,W'a"-%;44a - 7� h4zt . Fes^ 1- F, ic4 ^ s ,lr 1:fir ;_ + :� a Oae Only The Commonwealth of Massachusetts Permit NocA 9Gly • ... =' .Occupancy.& t o eh.hedrbt o) el r Department of Public Safety 3/90 (leave biankt /0; -I 1 BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 APPLICATION FOR PERMIT TO PERFORM -ELECTRICAL WORK All work lobe performed in accordance with the Massachusetts Electrical Code. 527 CMR 12:00 11 (PLEASE PRINT IN INK OR TYPE ALL INFORLfATIO%t49 JLU j D eU ..i12_\ S I Q�� City or Town of V'J i lot To the Inspector of Wires: The undersigned applies for a permitpp to.perform the electrical work described below.. 741411 q/? / LC location (Street & Number) ( \a 5 i,a(ilt-, --4-5c-9ND L-+9N�- / C� Owner or lenant G&tJG - as BC/{-r, 1'a Owner's Address Is this permit in conjunction with a building permit: Yes 91 No ❑ (Check Appropriate Box) Purpose of Building b i- (I , NC1 Utility AuthorizationNO. - Existing Service 4-CO Amps ( 15 / Z3J i ' Volts Overhead ` Undgrd No. of Meters ( New Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters ` Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work GO R -i i , c- J-m oi 7/OOfL- No. of Lighting Outlets ILl No. of Hot Tubs No. of Iransformers Total KVA No. of Lighting Fixtures ly Swimming Pool Above❑ -d. ❑grnd. g Inrn Generators KVA No. of Receptacle Outlets 2 No. of Oil Burners No. of Emergency Lighting'-1 Battery Units No. of Switch Outlets it No: of Gas Burners FIRE ALARMS No. of Zones No. of. Ranges No. of AirCond. Total No. of Detection and - tons Initiating Devices No. of Disposals No. of Heat Total Total Pumps Tons KW No. of Sounding Devices No. of Dishwashers Space/Area Heating KW No. Self Soondiig oft Devices No. of Dryers Heating Devices KW Local❑ onnection❑Other No. of Low No. of Water Heaters KW Signsf Ballasts Wiring No. Hydro Massage Tubs No..of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YESU NO0 I have submitted valid proof of same to this office. YESg NO If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE IS BOND ❑ OTHER Q (Please Specify) Estimated Value of Electrical Work S v360 (Expiration Date) Work to Start Inspection Date Requested: Rough 42,6"dgo1 Final re Signed under the penalties`oft perjury: 0h3�'''�- a ��o 3 '� FIRM NAME_GI~ vj- EAJ,3 OOD — ELECcca\CIAnJ LIC. Nfa. a-( 4338 CIF F yj M1) W 00 t0 Signature ,, Q , C 100-nt( LIC- NO. Al 103 Address lb fl(Z I-Fi 1Zo/ -O W&Sj Pori t"k A 02.7c{Jus. Tel. No. 4036 • (e 1o0Q> 5 Alt. Tel. No. (93(0-(0(90S 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) CO Ielephone No. PERMIT FEE ' (Signature of Owner.or Agent). BC-44A 4 4 RECEIPT FOR PERMIT _ TOWN OF DARTMOUTH ��� "� PERMIT NO. t x Lsvi F No v �i(�(_ Q S Date /,7-_5 b r/ Received From f //j;� 2 2 - - 7I CC Owner -�.;Ail,1 ,P ,,..2- . to fin-. i Location /f ' . L. �.�_�g1.{„R,,, Type.(*" /l /24.1t4 s r ,^, Amount *- /Paiid ' / 9 G� g , 37�Z Received _ .-,C_ce 7A,A_-_, . _ ' The Commonwealth of Massachusetts a'� =•bt Department of Industrial Accidents r 'C Office df/ ags 600 Washington Street ,4% Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Annti�m-mfntvtt^tiara—'.^= nar Of 0 Ic-.c'•^n• H S\At(4 \e Lps-ri1 city AM �2 OJ �� ohnne:e E i am a homeowner performing all work myself. am a sole proprietor and have no one working in any capacity ' t i am an employer providing workers' compensation for my employees working on this job. C9' companvname: l'e-t11--) WODO el G21-GI/3rj .. address: ( 3 �� \ 2Q� .. _. _... _ . . .. city: \_ S zfiT cc) oItnned. L5- e. to m U F S Y- svranceco- poHeva: . ._ ..:.:... - E i am a soie proprietor. general cnntract.Jr. or homeowner(curie one) and have hired the contractors listed below wr. the following workers' compensation polices: company name, address: . ... . bit.• nhnne* insurance co. .00iiereet company name: address: .. el !Atone* insurance co. -'Atta eva additional s eetif ineasan- - . . - Failure to secure coverage as required under Secnon 25A of MGL 152 can lead to the imposition of ertminal penalties of a fine up to SI_°00.00 one ears' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine ofSI00A0 a day against me. I understand copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby centre under the pains and penalties ofperjury that the information provided above is one and correct ci_ratere•-• - Ali Date \2-- c Print name l \ wcz>O Phones# (.1)3 -lacc`o official use only do not write in this ant to be completed by city or town ofIIdsi • city or town: permit/license d Qnuilding Department QLicensing Board :neck if immediate response is required QSeleetmen's Office °Health Department contact person: • phone 0; r Other 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 even• 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 ieaal entity, or any two or 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 entire', 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 _rounds or building appurtenant thereto shall not because of such empioyment be deemed to be an empir. MC-_ :hapter 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 char.:et been presented to the contracting authority. • \ppiicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation a..c supplying company names, address and phone numbers as all affidavitsmay be submitted to the Deparr,rent 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:he permit or license is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are requir: 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. rue Department has provide aspace at :he bon; the affidavit for you to fill out in the event the Office of Investigations has to contact ydu regarding the applicant. P be sure :o fill in the permit/license number which will be used as a reference number. The affidavits may be ren:r..e_ 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 questi please o not hesitate to give us a call. T:.e 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 =: (617) 727-' 49 phone 1: (617) —27—:900 ext. 406. 409 or 1375 . : . . .. COMMONWEALTH OF MASSACHUSETTS DIVISION OF REGISTRATION OF ELECTRICIANS AS A REGIJOUERNEYMAN ELOCTRICIA m . GLENN A WOOD N 88 DRIFT RD WESTPORT -MA 02790-1206 comaszmuccia27638 E 07/31/98 992827 CONTROL# 101.0486, . . IMPORTANT _ If this license is lost or destroyed, notify your Board at the Division of Registration, 100 Cambridge St., 15th Fl., Boston, Mass.02202. If name or address shown hereon is changed notify your Board of correct name or address to insure proper mailing of next Renewal Application. Always refer to your license number. License is subject to the provisions of the General Laws as amended. It is a personal privilege, and must not be loaned or assigned to any other person. Keep this license on your person or posted as required by law.