HomeMy WebLinkAboutBLDG-19-000565 MASSACHUSETTS UNIFORM'APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
:=_;11- CITY : G1 k s... . ... -.-f .o ( MA DATE 7-.2.Y-leis I PERMIT#sv6/9-wos`�5-
4,..:5:-....11/ji S J ---- .. -IOWNER'SNAMELD , ._ . .PA `at .SG _._ . ..
OWNER ADDRESS JS-2.2---iii- T • ITEL' 32S 3 Sf/ _I FAX,` —__.. ._..1
TYPE OR OCCUPANCY TYPE COMMERCIAL',') EDUCATIONAL';,,, RESIDENTIAL.
PRINT
CLEARLY NEW:54 RENOVATION:•._{ REPLACEMENT: ..._( PLANS SUBMITTED: YES_i NOi,J
APPLIANCES 1 FLOORS-, ESM 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BOILER !I�' I ... _I i_I __I,. .
BOOSTER ._...
CONVERSION BURNER __ _- --
COOK STOVE l;„_l.;I_ I _ '....,....1 I .._._,! _I ,_ 1, I'.-._...1. _ 1.......-I__-.._'
DIRECT VENT HEATER 1 ...._.._!.____ _._.,1 . , 11 . ; ____I_,,.1 ____ ,,,1'___1 1'._.,, .!_-_..'
DRYER _._._1', I __T!!..__: 1_1_._1 ___..I_____1'.____I_._ 1 _.T.I__.!
FIREPLACE ,_._I __ J_I- .I , I '..___,:__1 ___i._._1 __,-1..__1 ....._.1____:
FRYOLATOR 1—._1 .. — i 1' _ _11, 1_ .._i .--__1'..___I -_ f _.i _._ 1 . . `
FURNACE i __J.; _I'_..__I i ..,1 ...,....!I_ _____!,,,,t.__.,I • I 5 ,._JJ_...__`
GENERATOR _`i ..._--' _. ! _I _ _( �' 1
GRILLE - 1 1 _. _ .—I-- F
INFRARED HEATER I '' T J, _I i __ . t
LABORATORY COCKS -,.... .L--_,:.,.......,J,
MAKEUP AIR UNIT ,•,,,, „ •$---_ , ...._..1t,„„1 .–._. I ,.,...! ..._.1 I.
OVEN !_—J r..,_.:' 11 _21____I . 0_._._.1 _.,,.I ,,.4 ' .,,.,,...' ..._._!_.._1,._,_....: _.---,
POOL HEATER 1 1 T J' I i _!___
ROOM ISPACE HEATER 1 ' t' _1_ _1 __I. __J_I ___J____�.i__1 __,_i=„4 i
.
ROOF TOP UNIT _I ,T' n l' - ! I: :___J - 1 _ _ .....:_I __I ._._
TEST • . I ___jI' ' _ i_;1__. ! J I _ I ' ,.._! I , !1 1.___ ----CUNIT HEATER ....__S
UN
ERTED ROOM HEATER _ _I —t' ; _1:_1__!L� _ `_! i —1 i_I-'�' ____1
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OTHER...._. .. .__ ._ ..-._ ._ .. -. - 1 1_I ' 'I; I L_t—J___I.._J —__1
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I ' . I,' 1 I I',. I_ 1 .___.I__._.1 .11._...3 _,___! ____I
'. 1 11_ t - !,._.__ _._.....i 1...L..I __.I __1:j ____! ____I__.1 _--• ---I /\.1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I!I NO !-.j
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY +,J OTHER TYPE INDEMNITY __J BOND Li
OWNER'S INSURANCE WAIVER:l 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.
CHECK ONE ONLY: OWNER ..j AGENT i_}
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 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 compll ce with all Pertinent provision of the '
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Zayag ,
PLUMBER GASFITTER NAME STEPHEN A.WINSLOW i LICENSE#: 12298 SIGNATURE
MP.LI MGF.,J JP J JGFLI LPG! j CORPORATION•,!]#;32810 IPARTNERSHIP._I# 1LLC J#.
COMPANY NAME: E F WINSLOW PLUMBING&HEATING 'ADDRESS:8 REARDON CIRCLE I
CITY SOUTH YARMOUTH 3 STATE i MA 1 ZIP1026644 'TEL'508 394 7778 I
FAX•508 I CELL'NIA 'EMAIL'accountspayable@efwinslow.com I
=,— Department of lntitistrtatscctaenl s
5
i,.,=_--r,„—mot= t Office ofInvestigations
5 Elf►nl= Y 600 Washington Street
LY Boston,MA 02111 -
, . ` www.rnassgovidia '
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information j Please Print Legibly .•
Name(Business/Ortglanivntionilndlvidual): E.c.W,„Ns ov, Q1U��oiricl �. r1{a\..), ce, 1int.
Address: ' Q.eadan Circle._ ••
City/State/Zip: Sou kis 'wrc,.-k Or Phone#: `SOS-319-Inc/ •
Are you an employer?Check the appropriate box: Type of project(required):
,,cI am a employer with 70 4. 0 I am a general contractor and I 6. 0 New construction
.employees(full and/or part-time).* have hired the sub-contractors
1.❑ I am a sole proprietor or partner- listed on the attached sheet.* 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. 0 Building addition I
[No workers'comp.insurance 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
• required.] officers have exercised their
t.❑ I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions .
myselfL[No workers'camp. c. 152,§I(4),and we have no 12.0 Roof repairs
• insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
my applicant that checks bok#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.
:oonttactors that chakthis box must attached an additional sheet showing the name of the sub•contractora}ad their workers'comp.policy Information.
ism an employer that is providing workers'compensation insurance formy employees. Below is the policy and job site
rormdtion. n � . (�
isuranceCompany Name: AYYD+.J CioklosA ,`�n•PtxunCt2 \ ar" ey
oliey#or Self-ins.Lie.#: I$::).1 A Expiration Date: I-1 — aon •
its Site Address:a3 CenAry on w-e e.-(I-h y CC`e311‘'I4 Pi; City/State/Zip: 6,18-1 to 7
.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 a:ainst the violator. Be advised t t:t a copy of this statement may be forwarded to the Office of
•
tvestigations • the NA for insurape- ,overage veri a on. t
do hereby certify u ,r 1. rr penalties jury that the information provided above Is true and correct.
atu4. a ate* t a l x01 g.
bone ft: S •211/41• 777g \'
Official use only. Do not write in this area,to be completed by city,or town offictaL •
City or Town; Permit/Llcense# V
1.IsBoag rdofHraly th 2.Buildin: •
,_v'
1.BoardofHealth2.BuildingDepartment 3.City/l'ownClerk 4.Electrical Inspector 5.Plumbing Inspector
\ \
6.Other
Contact Person: Phone#:• o\
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