EP-14984 i
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_ ` _ _ _ The Commonwealth of Massachusetts
a" = / Department of Industrial Accidents
Officeofll esif�� p81/ODS
I•, 600 Washington Street
�;r_; Boston, Mass. 02111
`— Workers' Compensation Insurance Affidavit
�plic rtt.-infrmattonr •:- :. ...�._:N:sy ;e I e::
name: / .Kd.r/ a✓ ,i i-4...S.
location:
city
phone#
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity •
i, I am an employer providing workers' compensation for my employees working on this job.
company name: N.A.C.SECURITY . STEREO SYS...27. . ..
832 R Main Road
address: Westport,, MA 02790-4311
ctn.: phone#; `t? ?;s e— s 2 6 ‘
insurance co, b,95:,ri7, / 2.?_rv,,,cr v policy#: i n• 7..7 2 /
... - _,•:__u,yt-._`: ,.. ...-.b.'����:4�iirr.' ..4c :`.....:cr:.:-:y. :a:.;.d.c..4..,.,..,w;::Wio�y:-••-r�,_.'�a•�i•. _. :'-. -.
Cj I am a sole proprietor, general c,,intractor, or ho eowner(circle one) and have hired the contrarturs listed below who
the following workers' compensation polices:
company name:
address:
city: phone*
insurance co. • policy* _
. - - . . --. . - , =::-:s•r--•t-£?--.., -nic raw.-.u...,c d[mE - ue-- —.- --,r�,;F`^T •• _ .
compare• name:
address:
city: plume•# -
insurance co, : .. DOltevir'i> ...;, :••: ;
Atiieh id did onalsifeetff ire ceasarv— . -. — r,.'. 1:3-.,.?2 £. .,.. 4" :..y"•:, .s: ...
Failure to secure coverage as required under Section 25A of AMGL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 al
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day against me. I understand t
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
•
I do hereby certifi•un the pains d p aide pe ' rr that the information provided above is true and correct.
Signature �� Date 69%y 47)
Print name 5J /� ram E ,.: i Phone# oel�l�/ 72 i e
. official use only do not write in this area to be completed by city or town official •- I-
cin•or town: permit/license# OBuilding Department
i; DLicensing Board
n check if immediate response is required DSelectmen's Office
F.
contact person: phone# D
; DOtber Department
TOWN OF.1 DARTMOUTH
4 A 9 R A
BUILDING RECEIPTS
COLLECTOR'S OFFICE
i , ---
Name: f • -, -,_ r „, , , -I , Property ,...;' ;1'1_1,1 (7, I It ----- Date: ,s,/ ."--' '1'' i
,
> / •
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- s ,
v -'' 1 4 I / ` ! ' ''''. Owner:
Job Location: /,, , 3( , ^\'riT'''
4 7 lif 7 1L„( .,, r''''' _s'.'''
White Copy-Collector's Office
- t (P\-' " Yellow Copy-Customer's Receipt
Plot: 4....,...- Lot: , ,i,4 _ i i ,,,. „
i, i 'kJ' i , i , Pink Copy-File Copy
.
,...,0 - Green Copy-Building Department
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Phone:
2I
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Description General Ledger#'s ' Ref.# Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105
,--
License&Permits-Electrical 01000-44106 --. .,,....,,/,
'''''
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: -4----
—- TM The Commonwealth of Massaaiiusetts Permit
.L Occupancy&Fee Checked
• - C� (leave blank)
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Department of Public Safety •
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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 IZ:QO
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date . d �Z
-20.1 The undersigned applies for a permit to perform the electrical work described below.
Location (Street&Number). 9 /A '.6%ez a.f ,2.0
Owner or Tenant ..47�/*c . 14.?A/6'e L e •
Owner's Address
Is this permit in conjunction a building permit: Yes 12 No ❑ (Check Appropriate Box)
Purpose of Building zs' L'—Ir0,a '•..i ✓fie G Utility Authorization No.
Existing Service Amps. ( Volts Overhead 0 Undgrd ❑ No. of Meter
New Service Amps I Volts Overhead 0 Undgrd 0 No. of Mae
Number of Feeders and Ampacity •
Location and Nature of Proposed Electrical Work •g'-';"7 --s-J' i —�
No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA
No. of Lighting Fixtures Swimming Pool gnAtve Q ,:rod, ❑ Generators KVA
i 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
t
No. of Ranges No. Air Cond. Total No. of Detection and
Tons Initiating Devices
No. of Dis sacs Heat Total Total
Po No, of Punros Tons KW Heat of Sounding Devices •
No. of Dishwashers Space/Area Heating KW No. of Self Contained
DetectiontSounding Devices
No. of Dryers Heating Devices KW Local ❑ 8minnciP?l
ecnon 0 Con Other
No. of Water Heaters KW S o. f No.
Halli Low Voltage C��'j
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 Completed Operations Coverage or its substantial equivalent. YES NO❑ I have submi_
valid proof of same this office. YES NO LI If you have checked YES,please indicate the type of coverage by checking the appropriate
INSURANCE ZBOND 0 OTHER 0 (Please Specify)
(hapuanon Da<<
- •— Estimated Value of cal Work S %o. � //
Work to start 4,740 Z/� Inspection Date Requested: Rough � 'J� G'D Finalj�.L .,6)
Signed under the penalties of perjury: --
FIRM NAME . . e. flcvzv>- J s-e J��-- -ems e LIC. NO, a--ye
Licensee r-.J ..Alt Si C. NO. f-f
N
Address 73 2 ie ,.,/ /4q., �z,1T�aa 7— / O2 Bus.lt. Tel.No. ,A 9 f
�D Alt.Tel .�"L� � erfLf`—
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 signature on this permit application waives this requirement. Owner Agent (Please check one:
Tei•cnone No. PERMIT =EE S.
Signature of Owner's Agent Aar
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APPLICATION FOR PERMIT TO INSTALL AND REQUEST FOR ELECTRICAL SERVICE
Inspector of Wires-Town of Massachusetts
Customer on(Street#)
Lot# in the village of utility pole#or underground#
Customer's billing address
Temporary New Installation Change of Service Starting Date
Job Description
Service entrance voltage Amperage Phase
Wire size(cu.or al.) Conductor per phase
Number of meters Water heater Off peak: Yes . No
Electrical Contractor License# Telephone#
Address
Additional Remarks
CERTIFICATE OF INSPECTION
To the COMMONWEALTH ELECTRIC COMPANY. The installation described above has been completed and has this day been inspected and
approval granted for connection to your service.
Inspector of Wires Date
166 WIRING INSPECTOR TO BE NOTIFIED WHEN WORK IS READY FOR INSPECTION
Permit is Good for One Year From Date of Issue