EP-73923 i
0TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT t �° J 13
PHONE: 508 9 2 508-910-1838a m
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Name Y �,e Property Owner: + Date: t r°:' /r
Job Location: / r 'I/v/ ./ ....,..--- i
: , F�' ' r ap. i 1 Lot: i
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a r'tt,u`4 COL.LECTC'r.,
Description General Ledger#'s Ref. # Amount
Building & Building Misc. A 0(I-ii4 t95'
Electrical 01000-44106 (,;/ -� 2-- .2r ) 'i
Plumbing & Gas 01K107
Trench Safety 01000-44129
Other Department Revenue 01000-42420
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White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By"'-' 1 x
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
Application Number: _ //�� G.I.D.#: ?eh
l..ommorcwealth o/Madded ettd Offici j 1 3
h, 4 �7 Permit No • _
� '''''Aim- i department of ire Serviced
-� = Occupancy and Fee Checked'�-� p Y
:.: BOARD OF FIRE PREVENTION REGULA IONS f Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO P FO -M ELECTRICAL WORK
All work to be performed in accordance with the Massachus ectrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 6/0
City or Town of: hfOhth Dl'j/ j/-i To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) If hne 19i fit& A Parcel ID:
Owner or Tenant r tt1 /jjl cig' Telephone No. 77'-929 J4////
Owner's Address �4/)' �, thaie-
Is this permit in conjunction with a building permit? Yes n No (Check Appropriate Box)
Purpose of Building 5n,16.gudiI/,j R`ajI Utility Authorization No.
Existing Service 2O Amps 1 tl'v / itiV Volts Overhead n Undgrd n No.of Meters
New Service Amps / Volts Overhead Undgrd n No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Installation of roof mounted photovoltaic solar systems.
Ze modules= 6 kW
Con pletlon of the Allowing table may be waived by the Inspector c f Wires.
Total
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans T KVA
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting
grnd. grnd. Battery Units
V
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of AlertingDevices
Tons
No.of Waste Disposers Heat Pump Number Tons KW "No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Munonnecticipalion Other
C
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
HeatersSigns Ballasts
No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of EIectrical Work: ,/,2(0 (When required by municipal policy_)
Work to Start: l//(o/� Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAG : Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND El OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: V 1 V t'eft 30 ko V?... tveve! e 1,41... C LIC.NO.: 131 LI l
Licensee: ?‘r%11%.12 f. 7.42.0i f i le n A Signatur LIC.NO.: 1 3 ti y/A
iif applicable,enter"ex nnpt"in the license number line.) Bus.Tel.No.: 508-884-2411
Address: 370 Paramount Dr., Raynham, MA 02767 Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,l hereby waive this requirement. I am the(check one []owner ❑owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
1l
The Commonwealth of Massachusetts •
Department of Industrial Accidents
i- Office of Investigations
i 1 Congress Street, Suite 100
,; "� Boston,MA 02114-2017
',," www•mass gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individual): Phillip F. Zampitella
Address: 370 Paramount Dr.
City/State/Zip: Raynham, MA 02767 Phone#: 508-884-2411
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 10 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub-contractors b. ❑New construction
listed on the attached sheet. 7. 0 Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
. [No workers' comp. insurance comp. insurance.4
required.] 5. ElWe are a corporation and its l0.1n Electrical repairs or additions
'3.ill I am a homeowner doing all work officers have exercised their I l.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] c. 152,��1(4),and we have no 13.❑ Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: MJ Insurance, Inc
Policy#or Self-ins. Lic. #: 029342338 Expiration Date: 11/1/2014
Job Site Address: II PJI9I / avid /'d City/State/Zip: Al Opt hib, 4M 271/7
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi under s penalties o !jury that the information provided above is true and correct.
Signature: Date: h,/.,;/j�(
Phone#: /
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: