HomeMy WebLinkAboutBLDG-16-006366 •
-. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
(1_? CITY -Sq vl h Y[�!w +i r� j MA DATELLAS PERMIT# gab-4 Gd 617
-, JOBSITE ADDRESS 9 AS Wax# OWNER'S NAME
GOWNER ADDRESS 1.2X"'“?..- TEIL_S-,?c3 -& H ajFAX1
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL® RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:D REPLACEMENT:0 PLANS SUBMITTED: YES® NoEl
APPLIANCES 1 FLOORS-) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER -X1
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BOOSTER IT- f1:7-117-117:11-7.1771--11--1E--(17-11-7-11:-Th--1E:117-7. _- ... . ..- _ . ._ -
CONVERSION BURNER r---11771 j77-711-17 L 171.7fl_ __l7. II__ . .II (I_.._II ,- -i l__ .,-11^0
COOK STOVEI- 11-,_i
DIRECT VENT HEATER I_.__IL._Jr_ _ i. (I,- _il_ ..)!_.. II_.. (L ._711_ _.IL.. 11-
DRYER _1 (I. 71---11..7. - _.
tl 1 _ 1 _-.
1 . .{I., !I - _ll..- !1 11 IL IL____.)
FIREPLACE I. -. !I _II. _ _ I 1'_ - (I f II JI. .E. .._. I!.- _!I, . 1
FRYOLATOR i_. . II. I ilk . .11 . .'11 A__ L Intl __ii IL, ]'I" .1[11(-`
FURNACE -111111 . I iI_ .SI - l._ II -.II-- IL - II 11 - , .11 (L _ fl
GENERATOR 1. ... I__. !I .- 'I !! _ li - 11 II' .-,JI -_-. '1- . _.'I_ .. .
GRILLE II II l,fi -.. 11'-
INFRARED HEATERI. . .'.1 l._. I; __ 11-- _-II
LABORATORY COCKS • Ij 1117C 1` ) tr II _ . I;, il ----II t'
MAKEUP AIR UNIT • —1 Lu 'L~_/l-ml17.tllfl—(I ITT;I -11.1'TT I__I. II. I fL�
OVEN I- (!11.-._fl C-
POOL HEATER —'I. ,II .
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ROOM/SPACEHEATER _ _II - .`, 1 _- r--7-11-.--)I,, -.II --
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ROOF TOP UNITLI i (III III H II h 1 II II 1 _- 11—'IL__ II I
TEST —;I_ 1i h II ll (I__ (I II..._ ' i fl. !.
UNIT HEATER ' 1` '.li{ -11 _.l` � ' +I
UNVENTED ROOM HEATER 171 i{. 7. 3171E7k 117711-711_,
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WATER EATER ' —(1 ir!1_ ' I— _IL tI 11.. -.'I . 11 J I
OTHER -II __J _. . ll- - tl tl _L ,__ . ! . 1111-'1__- IL _._)l. .Jlil .l
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO U
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am 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.
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CHECK ONE ONLY: OWNER ® AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and 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,e with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' , / (-9-4, n r/
,
PLUMBER-GASFITTER NAME I STEPHEN A.WINSLOW 9 LICENSE# 12298 SIGNATURE
MPO MGFO JP® JGF® LPGI® CORPORATIONl#[35-16-1 PARTNERSHIP®#— LLC MIK
COMPANY NAME: EF WINSLOW PLUMBING&HEATING .ADDRESS InEARDON CIRCLE
CITY [SOUTHYARMOUTH— - STATE MA ZIP LcatITEL1508-394-7778
FAXI508-394-8256 CELL NIA I EMAILacountspayable@efwins!ow.com
w' Department of Industrial Accidents
l i,Sr (tOffice of Investigations
_reit 600 Washington Street • .
=_,,..m— 47 Boston,MA 02111 '
�Q.L Iwww.mass.gov/dia '
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): E.f .WI, SIom �(Vsn6irtc� 2 oc•Ai. c.) I�tt.
Address: g 4`P0aw1 cirri...
City/State/Zip: ScA '\ lent-ts.A-n NPr Phone#: 'UE-3`1'i.1 11'n •
Are you an employer?Check the appropriate box: Type of project(required):
,,{ I am a employer with '70 4. 0 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
;.0 I am a sole proprietor or partner-
listed on the attached sheet.t 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
10.0 Electrical repairs or additions
required.] officers have exercised their
1.❑ I am a homeowner doing all work . right of exemption per MGL 11.0 Plumbing repairs or additions .
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers'
13.0 Other
comp.insurance required.]
thy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation. .
tsuranceCompanyName: Arcel ,J f&J kaA ,.1 d1yc.xck.et(4._ tV ti.1
olic)/#or Self-ins.Lic.#: \ca a 1 A • Expiration Date: c—I — aon
)b Site Address:. 3 Cr t^1/4P-eel-tin / CF`251t4 OA City/State/Zip: Oat-167
.ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
allure to secure coverage as required under Section 25A of MOL c.152 can lead to the imposition of criminal penalties of a
ne 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
f up to$250.00 a da against the violator. Be advisedth�at a copy of this statement may be forwarded to the Office of • ��
tvestigations the DIA for insurapeC7overage verifiba4on. r
do hereby certify undar a ains an penalties o pe jury that the information provided above is true and correct.
ignatu : Date: (a' 31 1 ami
hone#: cl .%54, 7 77k
Official use only. Do not write In this area,to be completed by city,or town official • rt
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City or Town: Permit/License# y\ '
Issuing Authority(circle one): '\
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector �j J
6.Other .
Contact Person: Phone#:
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