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EP-253-95 ELECTRICAL PERMIT FIELD INSPECTION Dartmouth Building Department Plat: 079 400 Slocum Road-P.O. Box 793990 ot(s) : 6-8 North Dartmouth, MA 02747 ''f Telephone 508-999-0720 80. 00 Issued Date: 11/01/95 PermQ 253-95 Project Location: 18 Medeiros Way Number Street Subdivision Name: Nearest Cross Street: Electrician: Paul Medeiros Address: 216 Bellevue Street, New Bedford, MA 02744 Contact Person Phone #: (508 )991-2185 or 996-2082 License # 33820 Proposed Use: Residential Residential,Commercial, Industrial,etc. Permit Issued--To: Compl ete wiring new dwelling Type of Improvement,New Construction/alteration/addition/relocate 200 amps, 120/240 volts, underground, 1 meter, 10 lght out. , 30 lght fix. , 50 recpt. out. , 10 swtch out. , 1 range 1 dishwasher, 1 dryer, 1 oil burner indicate location of work(bedrm.,bath,living rm.,garage,etc.) indicate#of outlets/fixtures Owner(s) of Record: Paul Medeiros Address: 216 Bellevue Street, New Bedford, MA 02744 DATE TIME TYPE OF INSPECTION REMARKS INITIAL INSPEC. N 1-10 S i'.o o V-NW(.), •3‘ �✓� . > /,-;2 13 //M Z;ei /� ' P t Permit No. Office Use on The Commonwealth of Massachusetts5 3 " \ -5 * _ Occupancy&Fee Checked / _ cc---a ,' `'�— blank)/ _ — )-_ : Department of Public Safety (leave l//j 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) D / J C 1 J . ) , 19 9 J— The undersigned applies for a permit to perform the electrical work described below. ,e. t Location (Street & Number) I-01 i/t (.5 /L \/4 l) 5 P,R1 N( S J` ed e 1 l'O g L J O �% N i, MA Owner or Tenant Q 5 1 Co 0 Cep+ S 70 L'C'� �� 1-, 5fi N t`�G �r� Owner's Address �-� Is this permit in conjunction with a building pet Yes I_`'" No ❑ (Check Appropriate Box) Purpose of Building $i f1 l e ! ce i 1 )1 Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd Ey No. of Meters New Service z 0 0 Amps/ Z© / 2-P UJQlts Overhead Undgrd No. of Meters 1 Number of Feeders and Ampacity / ,V A J,,U••m i 0 L' _ . Location and Nature of Proposed Electrical Work W ► 11 C-- S i in i 'e Fel iM t k No. of Lighting Outlets J 0 No. of Hot Tubs 0 Total o. of Transformers KVA No. of Lighting Fixtures Swimming Pool ode ❑ grad. Generators KVA No. of Receptacle Outlets Q No. of Oil Burners i No. of Emergency Lighting Battery Units No. of Switch Outlets 1 0 No. of Gas Burners FIRE ALARMS NO. of Zones No. of RangesTotal No. of Detection and g 1 No. of Air Cond. Tons Initiating Devices Heat Total Total No. of Disposals 0 No. of Pumps Tons KW No. of Sounding Devices No. of Dishwashers it Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers I Heating Devices KW ❑ Municipal1:1Local Connection Other No. of No. of Low Voltage No. of Water Heaters KW 0 Signs Ballasts Wiring No. Hydro Massage Tubs 0 No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws ,,,.��jj I have a current Liability Insurance Polic,LY�.in, /�cluding Completed Operations Coverage or its substantial equivalent. YES t 3'NO ❑ I hytve'iubmittec valid proof of same t this office. YES Lt NNO ❑ If you have checked YES, lease indicate the�of coverage by checking the appropriate box. INSURANCE LtYBOND ❑ OTHER ❑ (Please Specify) C-e tl e L i CA ) 1111 y / U Estimated Value of Electrical Work$ 3000 ( xpirauon Date) Work to Start Inspection Date Requested: Rough Final Signed under the nalties of perjury: FIRM NA ct e • e' 1;CDe - (' 9 ' LIC. NO. 33 8 2t Licensee , • x e Signature IC.el 5 3 3 B G C7 Bus. Tel. No. Address 21 ( Re 1\ F' �' t 5 N ILk4 z 7 '- Alt.Tel. No. `Z- 0 IP 2 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required b} Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) y Telephone No. PERMIT FEE $ �67 (Signature of Owner or Agent) S 7 RECEIPT FOR PERMIT o�TH.y TOWN OF DARTMOUTH p2 _.)` 3 ..c, p^' i �� �s PERMIT N J 1 a o No (J`Z. 4 ,'Je94.5 Date // ,/ ,�)r^ 5 I w1 114 Received From ,/ --( f' =--`--.`'(..�..c,' '.r"t_' c2- , Owned ----4` 64- _ - -z�,.. ; Location l!� l�� ' -E—_ -e."' -",�." ,`l,, -.,, Type iw.€A - y Amount Paid Received By ` " ,'v- 'x"'; ..,,c_Ao `_ The Commonwealth of Massachusetts %1"5i;_ - � :z.e Department of Industrial Accidents _ '� aIa Oflicsoflaresilistfalls —_ /;_ 600 Washington ern freer �' �'z Boston,Mass. 02111 `— Workers' Compensation Insurance Affidavit 4pacantinformatnon:- .._ ._:..»)_ . 'lease:;pi ti Ng 1 i;i-: :,r,,z, :--:.Y_,: :.,,::,.... ..:F•V. nameT Pw1 li1/4.1\ eci z. vt-0 s — — -- location: 2-/ 10- ue leit ' CA- - city /�1p ci -_6 . lifL' Q S $ phone?1 9 9 /''7 1 r- [ a homeowner performing all work myself. Er l 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. . :.: .•.. . -nohty#= . .. . . I am a cole proprietor. general cnntractor, or homeowner(circle one) :ad have hired the contactors listed below who h the following workers' compensation polices: company name: - address: cit.. ._ phoone#- insurance co. ooiicv-#- - comnanv name: address: city: phonei#; - insurance co. `_Iyoiiky#:-- A ticia idditionai shill ifaeceasan-- - -- �-�, -- -- - �ti _ _ _ -_ _ -- _ Faiiure to secure coverage as required under Section 25A of MMGL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and, 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 cop} of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby cerrip• err pai d penalties of perjury that the information provided above is true and correct. Signature- . n 4���1,c . D 1/ — j --- �A j"_" Print name c4 u I ., \ e 4 c,f S Phone# ?l' / -- 27 el official use only do not write in this area to be completed by city or town official — : city or town: permit/license# t'IBuilding Department Licensing Board check if immediate response is required Selectmen's Office ` °Halth Department contact person: phone#; mother Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for the: 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 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 hou 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 Iocal 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 ha been presented to the contracting authority. _ _ +P• �4 i -_ - _ kppiicants 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 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 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. Plea: be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned tc the Department by mail or FAX unless other arrangements have been made. The Off-I.:: of Investigations would like to thank you in advance for you cooperation and should You have any questions please ::o not hesitate to give us a call. • 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 4: (617) 727-7 7 49 1 phone #: (617) 72 490F0 ext. 406. 409 or 375