HomeMy WebLinkAboutBLDG-18-007356 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS I1 S (c A-M ri Smti l l I�rsl f) I OWNER'S NAME (hfl S f! < /�'Gid/t' I
GOWNER ADDRESS Sp044.4 ITEL 50B2466Z11 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Er PLANS SUBMITTED: YES NOQ ,
APPLIANCES 7 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 ' 12 13 j 14
BOILERr
BOOSTER I
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER1
DRYERJr_ II I, _, 6
FIREPLACE i
FRYOLATOR F _;
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FURNACE '
GRILLE
GENERATOR f r f -I-- r
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INFRARED HEATER
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LABORATORY COCKS
MAKEUP AIR UNIT r r
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OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT y, r
TEST
UNIT HEATER I ,,i _1
UNVENTED ROOM HEATER fl �,�, I _ - ir
WATER HEATER
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INSURANCECOVERAGE
I have a current liabilityinsurance policyor its substantial equivalent which
meets the requirements of MGL.Ch.142 YES ❑NO 0
"• I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW '
LIABILITY INSURANCE POLICY ❑+ OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
o Massachusetts General Laws,and that my signature on this permit application waives this requirement.
C' CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
r l hereby certify that all of the details and information I have submitted or entered regarding this application are true ;n• accurate tor the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be In compli. e with all Pertinent provision of the
0— ,Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / i _
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PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNA -RE
NJ MP 0 MGF❑ JP❑ JGF❑ LPG!0 CORPORATION Q# 3281C PARTNERSHIP Oft LLC❑#
1`n COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE I
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CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
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— FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com
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The Commonwealth of Massachusetts
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Etta et Department of Industrial Accidents
iV 'A1'- 1 Congress Street,Suite 100
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Boston,MA 02114-2017
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Workers'Compensation Insurance Affidavit:General Businesses.
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t TO BE FILED WITH THE PERMITTING AUTHORITY.
y v Applicant Information Please Print Legibly
Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC
. I Address:8 REARDON CIRCLE
`ki � City/State/Zip:SOUTH YARMOUTH,MA 02664 Phone#:508 394-7778
...„4 Are you an employer?Check the appropriate box: Business Type(required):
1.1:1 I am a employer with 1C) employees(full and/ 5. 0 Retail
or part-time).* 6. Q Restaurant/Bar/Eating Establishment
2.0 I am a sole proprietor or partnership and have no 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.❑ We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c.152,§1(4),and we have 10.0 Manufacturing
no employees.[No workers'comp.insurance required]** 11.0 Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
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.
**If the 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.
I am 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.#1821A Expiration Date:01/01/20(9
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
V Investigations of the DIA for insurance coverage verification. -
\ I I do hereby cerci the a/' s and naltiessoo perjury that the Information provided above is true and correct
�� Signature: (�.� Y"--. awe, Date: ]a /3I I i
\ Phone#:508-394-7778
\ I 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
&Other
Contact Person: Phone#:
www.mass.gov/dia
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