EP-119-95 •
1E LE CTR 1 CAL I"' E M IT
FIELD INSPECTION
Dartmouth Building Department Plat: 079
400 Slocum Road-P.O. Box 79399 Lot(s) : 48-48
North Dartmouth, MA 02747
Telephone 508-999-0720 F $80.00
Issued Date: 08/28/95 Pe
Project Location: 37 Sundance Road 4y19-95
Number Street (/ �
Subdivision Name: v<"
Nearest Cross Street:
Electrician: Joseph Charpentier
Address: P.O. Box 488, Fairhaven, MA 02719
Contact Person Phone #: (508 ) 997-6053
License # A13039
Proposed Use: Residential
Residential,Commercial, Industrial,etc.
Permit Issued To: Install Underground/New Dwellina
------
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,ry..........t. .......,rr Y.C �- 'io_/4ltePr:....!...+.•A..
200 amps, 120/240 volts, underground, 1 meter, 15 lght. out. , 15 lght.
fix. , 50 rect. out. , 25 swtch out. , 1 range, 1 dishwasher, 1 dryer, 1 oil
burner, Will Call
indicate location of work(bedrm.,bath,living rm.,garage,etc.) indicate#of outlets/fixtures
Owner(s) of Record: David Bousquet
Address: Sundance Road, North Dartmouth, MA 02747
DATE I TIME TYPE OF INSPECTION REMARKS - INITIAL
(1 INSPEC.
1 .e9
SIGNED BY:
f 111, { f
Office Use()nib r
The Commonwealth of Massachusetts Permit No. yk. 1 -1 5
*_ Occupancy&Fee Checked ii gb,6'9
P;==.--...._fil ,-,....
=_ 12
Department of Public Safety (leave blank) y/1)(Os
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) Date /..i S J 2 e /«2 /4--
c
The undersigned applies for a permit to perform the electrical work described below. C
Location (Street&Number) '3 --SC(/?/ r"�f iL- (----.2-.2 /rt11.e 73
Owner or Tenant A9L'CV ,8G-i E .,j r4 a /
Owner's Address _S--- ,7
Is this permit in conjunction with a buildingpermit: Yes Ler No j ❑ (Check Appropriate Box)
Purpose of Building /6'Sri�, Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd r❑ No. of Meters
New Service Wimps /?.t/ / 2410 Volts Overhead ❑ Undgrd ILC. No. of Meters /
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work �/Z-0=/A /1 6/e99/97/1 41:4 , e.�!».y'
Total
No. of Lighting Outlets / ." No. of Hot Tubs •-- - No. of Transformers KVA
No. of Lighting Fixtures .5 AboSwimming Pool grid. ❑ grid. ❑ Generators KVA
No. of Receptacle Outlets o No. of Oil Burners / No. of Battery Unit Emergency Lighting
No. of Switch Outlets No. of Gas Burners FIRE ALARMS NO. of Zones
No. of Ranges Total No. of Detection and No. of Air Cond. Tons Initiating Devices
No. of Disposals No. of Heat P s Tons KWl No. of Sounding Devices
Space/Area HeatingKW No. of Self Contained
No. of Dishwashers P Detection/Sounding Devices
HeatingDevices KW Municipal El
No. of Dryers i 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 ❑NO❑ I hava,submitted
valid proof of same to this office. YES LJ NO LJ If you have checked YES,please indicate the type of coverage by checking the apprlipriate box.
INSURANCE QND ❑ OTHER ❑ (Please Specify) dt iV, - 'e ' .5- ,29,l'�i `.d
(Expiration Date)
Estimated Value of Electrical Work$ ,
Work to Start ;?Z s' "r, Inspection Date Requested: Rough j..a/ e/ / / Final l4 V// ?- //
Signed under the penalties of perjury:
FIRM NAME /1� i1�Ti�.'�' Ca/ 5 jam"i-c ,"'t c;- LIC. NO./5/-1,1
Licensee(-"-7,tit/%',e 7..i//--i` e-fie°.c Signatur 27 """ o — LIC. NO /,a�L,.3'/
�j us. Tel. No. `. 2tt /x 3
Address ./ C/' �C�'11�i e--A -t:/.7i2- ' i C— Al(.Tel. No. % C 7/ j 2
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does dt 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 of Owner or Agent)
Tglephotle No. PERMIT FEE $ Fr(-3 - «
RECEIPT FOR PERMIT _
TOWN OF DARTMOUTH k l 5- 9 k,�pUTu.44
g4r�7+ PERMIT NO.
a. . 4 aR
° -n, No 1 l c)
,e 4 Date N v , a 8 1 1`ii k
Received From LAS: CV\ s i.-
Owner \ k‘..s {4o,J •Sc
a
Location -1C_ 'C... 1
Type \ Lc'.k.`r An".k M k\‹.:a'a
Amount Paid % 1
a
Received By ,._..2; 9, �. -.?\r-a- ; .."• ---
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•
1
COMMONWEALTH OF MASSACHUSETTS
b^ DEPARTMENTOFINDUSTRIALACCIDENTS
_ 600 WASHINGTON STREET
James Camooe� BOSTON, MASSACHUSEr-is 02111
-om,-,:ssione•
WORKERS' COMPENSATION INSURANCE AFFIDAVIT
I, �� ,.---,
(licensees permirree)
with a principal place of business/residence at:
(City/State/Zip)
do hereby certify, under the pains and penalties of perjury, that:
[ ) I am an employer providing the following workers' compensation coverage for my employees working on this
job.
2 i A,,r'.. 1)4'/ ".0"'` / K-',...Z 312 — 41 W ,.'' 6:-O-3 5
Insurance Com any Policy Number
[ 1 I am a sole prop.letoi and Lave no one working for me.
[] I am a sole proprietor, general contractor or homeowner (cirde one) and have hired the contractors Iisted 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,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 S 100.00 a day against me.
Signed this 7. /�C. ' __ day of , 29 �
ensee: ermirtet Licensor/Permirror