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Home My WebLink AboutBLDG-19-000089 eic,-- y Jct261«ikbt,J IN MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F=.Ltd;`L•/ yt!fo zG CITY YV0A0JLi►n I MA DATE' G I Zi U 1 t `b I PERMIT# D4/T-oon38 JOBSITEADDRESS f 06s;gdtt5+i( Ave. 14,44011KOt 4OWNER'SNAME Narotd pi'nt J GOWNER ADDRESS 51,14,.(, I TEL 9'1$9 (9 5'494 JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ ED CATIONAL❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT;Do PLANS SUBMITTED: YES❑ NOD APPLIANCES? FLOORS–. BSM 1 2 3 45 6 7 8 9 10 11 12 13 14 BOILER IIIIiiiIiIIIIi COION BURNER i COOK STOVE DIRECT VENT HEATERIII I DRYER I ,` � 1 ,I �: FIREPLACE , II FRYOLATOR i, i. I itfr , I FURNACE t GENERATOR GRILLE 15�� I I J Q INFRARED HEATER i X11 LABORATORY COCKS I l� MAKEUP AIR UNIT r OVEN �l i POOL HEATER , ROOM I SPACE HEATER '�r ROOF TOP UNIT I J1 TEST N UNIT HEATER i ,1 I I 1 r OTHER ROOM HEATER S al WATER HEATER c•-% _,��,� �, � I ice' S I � l INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑NO ❑ 60 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW V� LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ❑ BOND ❑ Co 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. l-13 CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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 curate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be In complian ith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. sv�� PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 freiSIGNATURE MP C] MGF❑ JP E3 JGF❑ LPG'El CORPORATION❑+ # 3281C PARTNERSHIP EN LLC EN COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL NIA EMAIL accountspayable@efwinslow.com ke le 6 �� Sgka {'St. rV//f/.nne,r.NLM.VJ I..sea.;NY/.nut-ow Department of Industrial Accidents l _,7n�_ i Office of Investigations Er _ 600 Washington Street ti m:::Nr . Boston,MA 02111 ��' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information tall Print Legibly y� Name(Businesslorlglanization/Individual): EsF•In1t,�5Io �U,..�wrcl 8,.. �.ectV' �q \e.) I`�1(. I Address: 3' �Pddw, �ide- (J d City/State/Zip: Sc,)%n `erw,wC-tn NAr Phone #: "SOE- 399-117Si 1\ Are you an employer?Check the appropriate box: Type of project(required): SCSA Xam a employer with 'j0 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. 9 Remodeling �� ship and have no employees These sub-contractors have 8. 0 Demolition siS working for me in any capacity. workers'comp. insurance. 9• 9 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions L❑ 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 12.9 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp. insurance required.] thy applicant that checks box NI 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. Ar n isurance Company Name: Arit\,.t (—L i-ll� /1f tXG/t C2 \ e1 ''l✓ti olicy#or Self-ins.Lic.#: :S a 1 A• ` .' ''11 Expiration Date: (—] — aOI9 Ib Site Address:.)3 ``jewvesil1/4.P1•44.1 1 �� C(^233YIA Ylt City/State/Zip: O,-)r-I to 7 ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 1. ..:.ailure to secure coverage as required under Section 25A of MGL 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 sat a copy of this statement may be forwarded to the Office of i‘ tvestigations the DIA'for insuraI - ,overage verif a,on. do hereby certify un re arms a I penalties o p• jury that the information provided above is true and correct. ignatat • Date: 1a) 31 ail?. hone#: S1)1,114- 7 n 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): N 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other �' Contact Person: • Phone#: M \\ • '