HomeMy WebLinkAboutBLDG-18-005366 .\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-t CITY LI(1-- Qur. L. (�rL�T) • ;� MA DATE C % PERMIT# ; /1/7/7'�
lc
JOBSITEADDRESSI Gaff � /Lo OWNER'S NAME I .� - ,J
COWNER ADDRESS .S7 ---- 1 TEL5`0K775 S' 1FAX .-
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL[
PRINT
CLEARLY NEW:0 RENOVATION:E.1 REPLACEMENT:Fir PLANS SUBMITTED: YESD N01J
APPLIANCES 1. FLOORS--I BSM 1 2 3 4 5 6 7 8 9 10 11 . 12 13 14
BOILER FTy1. '1T.-1_ 7i l ^I:_. . 'I.-- °I: =41 :-.-.7 _ -'11 - 1:.-_''L L:..._i
BOOSTER = J1.1 _1.[ '1- _ [_ ._..I._�.i 1 �-'I. I--�':1 . ., '._-_1-I7. _i I-:.-_I., t(-... -,�:
CONVERSION BURNER Il` _�I[TT ET:'i 7_7IF-.71.77E7 ---.'is_::(...-T.:T,- :�-L_,�s.�tl-•..-.._ L=TMGI- _-
COOKSTOVE I�. 1_ 'I. -1_:M;; rL-_--_:I._ -:I^. i �_.-___1 __..I. i "L._ '`I:---
DIRECT VENT HEATER 1=-._-:1, _ l_�_7I.._- 71 -_•1 '.1_._. _.�I_.�,i -.F.: :c �..•(..�_..!r., 1.-. -.::I_-.. -i•
DRYER ,1-2-:-:2
1- -'I. ET::I.-'1 -- - -1-. L__� fti7i7- j�-__,(._. .�_',1':.1177. .I.
FIREPLACE Cr-,;-;:::
t-,; ;1-- .I..ET::FT-.
--- 1---..__:F�-- '----- --- I, _ :_. -=._
FRYOLATOR '::- 'L.:'-i:.._,I - -:�`- _1-_.-_}!._..�;h"---.I-. E ,ET:�._._._:I, 'LW. .:'•�I--~__
FURNACE I_ I_-._--r11_----7 L .� .) - - .- _1 I .:1, _ 1 , i_ :(:;�_ I `I.--_ ..'
GENERATOR 1 1 - ;..,_:.. : --- :11....-.,. . ._ ._ ;_... _,I_- ._3;1 'j �i�._,i. `(\
GRILLE • I x_ I. �' i I. _ l ;1- 1. Y L_.�. ._ ,;4,+.r_;1 :._ l .: . :Ir` ,.
INFRARED HEATER __I I. . 1.I. :I:` 7I,. L. I---�1_. _I:w_.w11-.- ITT.C.. _;.1, v�
LABORATORY COCKS .1 -- -1----1.�:.._ 1----7 I_•-`1I:_ . ,I-_�:i_._"._..__._.;1� : --- _i i.-' ...`'I. . •
MAKEUP AIR UNIT I 'fL .�.L_� , l.� _;:I.=. I.7 il._ - �,1�.. -.L ;.[ -1 -•:[T I. v_,E. .I ,,
OVEN I :...._-_-:_. L.-- -1 L` '.1[- ;r 11-.7 .-___:L._ ',1...�'1., :(. �il ,V ...(. 1177F
POOL HEATER I_~_ I -177(`_--i_ ---_1.--_a l�_.I_.---„(_-__1.: r ......:1...,......:.- (�.
_ __ 1, t.. Lz - rsCl
ROOMISPACEHEATER (._ 1----i(T.:1:ETD I�_ ',I. .~_.I.__._til..._.. I17:-:l+ ..11T.._:I:Th --:"- ..1-
ROOF TOP UNIT L:_-..iL� I 'I.. r 17.._ ;1---11---- 1,:::-::L7 i 7.7. . _.1 _-1 L-,:_ E......I. (�,
TEST I _ -? • ----. --.I7--•.; :r -----1--- 'I-=.i-=-•,---:=:,i ;I _ =7 _ V '
UNIT HEATER -,y L - ----•-<i.-- _��L,.. ...1._.._.I , _(- ,[ J 1- 1---;1_ ::I \
UNVENTED ROOM HEATER ,..-._11:::_. I..... 7ITT!L. •I�' :.:L._. ..Iw_ •r 1 ,--�:IL_ �r.711;
WATER HEATER . C- ',C--- 1r _.I- I, .-r--.I.- :•L.- . --- :r .Ir-. I_._... •
OTHER I '1 _ ;1:17.-_ 1'-. I_.......L, 1-7;17 _I� I-. - 17711 ` ._iil_ .;
• is I _T , =-•t ,I: ':I� 'I. 1-�_ !1:... . 1
il. ...II:.. . l„_ ..`I.�...:'I..-_:I. .,m. l_._."•_' ._ ',1.... L�. iL......�':1.1_v,� V
INSURANCE COVERAGE
t have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LINO E,,,
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY(l OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER Ei AGENT 0
SIGNATURE OF OWNER OR AGENT 1
I hereby certify that all of the details and information I have submitted or entered regarding this application are true a accurate to the best of my knowledge •
and that all plumbing work and installations performed under the permit Issued for this application will be In compile with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 ; SIGNATURE
� � - � l 1 LLC �# T
MPI h MGFED JP-1 JGF_ LPG!El CORPORATION0#13281C y PARTNERSHIP , 0' __
COMPANY NAME: EF WINSLOW PLUMBING&HEATING .ADDRESS 8 REARDON CIRCLE_ T-. ___ -_ -
CITY SOUTH YARMOUTH STATE MA ZIP I 02664 TEL I 508-394-7778 _________I
FAX 508-394-8256 1 CELL N/A _ JEMAIL accountspayable •@efwinslow.com -- � -_ - - -
3
•
The Commonwealth of Massachusetts
.• t Department of Industrial Accidents
r - 1 Congress Street Suite 100
Boston,MA 02XX4 ZQX7
j
www.macss.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE PH,ED WITH THE PERMITTING AUTHORITY.
Auplicant Information
Please Print Legibly
Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO.,INC
Address:8 REARDON CIRCLE
•
City/State/Zip:SOUTH YARMOUTH,MA 02664. Phone#:508-394-7778
Are you an employer?Check the appropriate box:
1.❑✓ I am a employer with 1 Business Type(required):
employees(foil and/ 5. ®Retail
or part-time).*
2.El I am a sole proprietor or partnership and have no 6 ❑RestaurantBar/Eating Establishment
7. 0 Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8. []Non-profit
3.0 We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c.152,§1(4),and we have 10.0 Manufacturing
no employees.[No workers'comp.insurance required]**
4.❑ We are a non-profit organization,staffed by volunteers, 11•®Health Care
with no employees.[No workers'comp.insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
*•*Ifthe corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
lam an employer that is providing workers'compensation insurance for my employees. Below is the.policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:23 COMMONWEALTH AVE •
City/State/Zip: CHESTNUT HILL,MA 02467
Policy#or Self-ins.Lic.#1821 A
Expiration Date:01/01/201 Attach a copy of the workers'compensation policy declaration page(showingthe 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.X do hereby certi r the a' and enalties a perjury that the information provided above is true and correct.
tY/ a
Signature: Date- 1 t f. •
Phone#:508-394-7778
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.Licensing Board 5.Selectmen's Office
6.Other
Contact Person:
Phone#:
www.mass.gov/dia