EP-153-95 79,PERMIr
6
ELECTRICAL
FIELD INSPECTION
Dartmouth Building Department Plat: 079
400 Slocum Road-P.O. Box 79399 Lot(s) : 048-30
North Dartmouth, MA 02747 Telephone 508-999-0720 CONIETTEM
Fee: $20 . 00
Issued Date: 09/12/95 Permit No. : 153-95
Project Location: 30 Sundance Road
Number Street
Subdivision Name:
Nearest Cross Street:
Electrician: George DeCosta
Address: 41 River Road, Mattapoisett, MA 02739
Contact Person Phone #: (508) '758-4251
License # 13746A
Proposed Use: Residential
Residential,Commercial,Industrial,etc.
Permit Issued To: Additional Wiring
Type of Improvement,New Construction/aalteration/addition/relocate= --
100 amp underground service, 220/110 volts, 1 meter 2 lght out. , 2 lght
fix. , 16 rect out. , Rough A.S.A.P.
indicate location of work(bedrm.,bath,living rm.,garage,etc.) indicate#of outlets/fixtures
Owner(s) of Record: James Demers
Address: 30 Sundance Road, North Dartmouth, MA 02747
DATE TIME TYPE OF INSPECTION REMARKS INITIAL !`
I NSPEC.
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c\\VZ-N4 \113 CM � �4a-\ b� . P, k-,
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T N t Office Use Only e, ,
The Commonwealth of Massachusetts Permit No.
I =** r Occupancy&Fee Checked ion C--. 6
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` - Department of Public Safety ( �1 —/ 5
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 CJwIRi12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date . 1/7////15
The undersigned applies for a permit to perform the electrical work desc 'bed below.
3[Location (Street&Number) _>G(i,�4s-y ee Cit• f7Y , 3 0
Owner or Tenant 0 -/ /(-6--(_.- -YY2-f 41______
Owner's Address ,_92/»e
Is this permit in conjunction with a building permit: Yes a❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service /c3 Amps a 4- / ; ha Volts Overhead ± Undgrd g No. of Meters
New Service Amps / Volts Overhead E Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work GJ,f L .-? (je t't ti dis -t Call
No. of Lighting Outlets No. of Hot Tubs Total
.l No. of Transformers KVA
No. of Lighting Fixtures Swimming Pool Above ❑ grnd. ❑ Generators KVA
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
Total No. of Detection and
No. of Ranges No. of Air Cond. Tons Initiating Devices
Heat Total Total No. of Sounding
No. of Disposals No. of Pumps Tons KW Devices
Space/Area HeatingKW No. of Self Contained
No. of Dishwashers p Detection/Sounding Devices
No. of D ers Heating Devices KW ❑ Municipal n
=Y Local Connection Other
No. of No. of Low Voltage
No. of Water Heaters KW Signs 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 Polic mcludin Completed Operations Coverage or its substantial equivalent. YES ill NO ❑ I havet submitted
valid proof of same to this office. YES Li NO LJ If you have checked YES,please indicate the type of coverage by checking the appropriate box.
INSURANCE ❑ BOND El OTHER ❑ (Please Specify) (Exp{ation Date)
Estimated Value f Electrical Work$
Work to Start //G 5� Inspection Date Requested: Rough 7 54 p Final
Signed under the penalties of perjury:
FIRM NAME e 0 ,-e, nt: C fr; (j LIC. NO. /37 4/4 ;e)
Licensee c�?, • ",L =•I Signature 47.4_4r _,-,)- LIC. NO. :'
(} Bus. Tel. No.
Address /1 1 +�14>t'a F 1 /444//11u:5777/ f k g' Alt. Tel. No. 7 _C q0 _
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or t bstantial equivalent as required by
�M husetts Gener 1 La , and that my signature on this permit application waives this requirement Owne Agent (Please check one)
�-'�.4- Telephone No. ' --5:501.0 7 PERMIT FEE $
(Signature o wner or Agent)
RECEIPT FOR PERMIT
TOWN OF DARTMOUTH / 6j — . 5
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PERMIT NO.
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Date (/
keceived From
cNvner ���
Location vc 2
Type -�U
Amount Paid c9 G
'U Received By
RECEIPT FOR PERMIT
TOWN OF DARTMOUTH / h 5 .- 5'
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Received By ,,V 4,... " " "�'
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COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF LNDUSTRIAL ACCIDENTS
600 WASHINGTON STREET
James. Camooei, BOSTON, MASSACHUSEi iS 02111
P-om^.+asione•
WORKERS' COMPENSATION INSURANCE AFFIDAVIT
I,
(licensee/permi tree)
with a principal place of business/residence ar.
(City/State/Zip)
do hereby certify, under the pains and penalties of perjury, that:
[ J I am an employer providing the following workers' compensation coverage for my employees working on this
job.
Insurance Company Policy Number
[] I am a sole prop.:etox and have no one working for me.
[] I am a sole proprietor, general contractor or homeowner (circle one) and have:iirec the:_x.:'tractors 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
4I am a homeowner performing all the work myself.
Pe g Ys
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,sect. 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 S100.00 a day against me.
Signed this dayof 9/
9
Licensees Permirtet Licensor/Permittor