EP-675 ELECTRICAL PERMIT
FIELD INSPECTION
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Dartmouth Building Department Plat: 079
400 Slocum Road-P.O. Box 79399 Lot(s) : 048-48
North Dartmouth, MA 02747
Telephone 508-999-0720 Fee: $80. 00
Issued Date: 04/06/95 Permit No. : 675
Project Location: 19 Southwind Way
Number Street
Subdivision Name:
Nearest Cross Street:
Electrician: Wayne Simoes
Address: 374 Cross Road, North Dartmouth, MA 02747
Contact Person Phone #: (508 ) 999-1746
License # 26921
Proposed Use: Residential
Residential, Commercial, Industrial,etc.
Permit Issued To: New Dwelling_
Type of improvement,New Construction/alteration/addition/relocate
200 amp underground service, 110/220, 12 lt. fixt. , 40 rec. , 1 range, 1
dishwasher, 1 dryer, gas burner est. cost $2, 000. 00/w.c.
indicate location of work(bedrm.,bath,living rm.,garage,etc.) indicate#of outlets/fixtures
Owner(s) of Record: Bob Viana
Address: 2 Malbone Road, Assonet, MA
DATE TIME TYPE OF INSPECTION REMARKS INITIAL
INSPEC. it
-� -95 io � t� `CtZ era
G -t
S
0
Office Use Only
The Commonwealth of Massachusetts (��
Permit No.
**=s / e a Occupancy&Fee Checked_ l "-C �-�
IV`M- Department of Public Safety (leave blank) ,J
imi
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 q_c v
l,s
The undersigned applies for a permit to perform the electrical work described below.Location (Street&Number) /67 (t)�3 l I )\ ,7 �/. - 7�1
t
Owner or Tenant Ac./3 (1; o A
Owner's Address rol-1-- j ) ' kr - k'E2'JJ 6 a)Is this permit in conjunction with a building permit: Yes No E (Check Appropriate Box)
Purpose of Building Rt------S/nf-`V I - Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps PO O / 2 7 DVolts Overhead C Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work lV ----CO g v S-
C—
otal
No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA TVA
No. of Lighting Fixtures S -1i Swimming Pool Above ❑ mod. ❑ Generators KVA
No.No. of Receptacle Outlets !LY 0 No. of Oil Burners Batteryof UEnits
rgency Lighting
No. of Switch Outlets No. of Gas Burners j FIRE ALARMS NO. of Zones
No. of Ranges / No. of Air Cond. Total N . of Detection and Tons Initiating Devices
Heat Total Total
No. of Disposals No. of Pumps Tons KW No. of Sounding Devices
No. of Dishwashers i Space/Area Heating KW No. of Self Contained
Detection/Sounding Devices
No. of Dryers 1 Heating Devices KW Local ❑ Municipal n Other
Connection
No. of Water Heaters KW No. of No. of Low Voltage
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 includin Completed Operations Coverage or its substantial equivalent.. YES ❑NO ❑ I have„submitted
valid proof of same tot ' office. YES LJ NO LI If you have checked YES,please indicate the type of coverage by checking the appropriate box.
INSURANCE LJ BOND ❑ OTHER ❑ (Please Specify) / ? '`-
(Expiration ate)
Estimated Value of Electrical Work$ !DO
Work to Start A S,.1' Inspection Date Requested: Rough Final
Signed under the penalties of perjury:
/penalties,
)of
NAME [J-- / � \\ LIC. NO. 1
Licensee /]it'l�C Signature lit/ 4�� LIC. NO. ? /2r L:
j � t [ Bus. Tel. No.
Address 7 V C 'G-SS /,Fl- k)6- 4/(./�'i: 114 Alt.Tel. No. 9 f-/7 VC
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by
Massachusetts General Laws, and that my signature on this pam'it application waives this requirement. Owner Agent (Please check one)
Y Telephone No. PERMIT FEE $ '61
(signature of Owner or Agent) //
RECEIPT FOR PERMIT ,,
4� urx.y� TOWN OF DARTMOUTH �
PERMIT NO.
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y - = No
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Date � �' - 2 �J..
Received From G "` `..e, f 21 ' ? ". rv— -9--E-t
Owner , . !! �' ,v
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Location / -,' -- 0.-^''d"`-`'` k" 1'
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Type .....,-- GA,...,.-4_0---.
(' 4..„. -.-:,--. i• 2
Amount Paid 6/
Received By i;t ' - �_ a
A
" T COMMONWEALTH OF MA.SSACHUSETTS
, + DErARTMENT OF INDUSTRIAL ACCIDENTS
600 WASHING`I'ON STREET
Camoaeu BOSTON, MASSACHUSETTS 02111
iNmpmn!ssione'
WORKERS' COMPENSATION INSURANCE AFFIDAVIT
I,
(licensee/perm i ttee)
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 „'' i
job.
Insurance ompany Policy Number
( I am a sole prep.ic-ai and have no one working for me.
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors li4i,„4
who have the following workers' compensation insurance policies: 1
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
p 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 wk,
dwelling of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto are not gc,,$
to be employers under the Workers' Compensation Act(GL C. 152,sect.
or permitconsideredmay evidence the legal status of an employer under the Workers' Compensati(on,Ae�tpIicatioa by a homeowner far, 10,�,
I understand that a copy of this statement will be forwarded to the Department of Industrial Aeddenu'Office of Insurance for
verification and that failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of crimiruw{ ''4
consisting to
Si �00.00 and/or imprisonment of up to one year and civil
fine of S 00.00 a day against penalties in the form of a Stop Work Or, ���,4 i•
f:
Signed s � l day of APg I L- , 19 % 5
,c7c
licensee/Per rrcc Licensor/Permittor