HomeMy WebLinkAboutBLDG-19-000290 .i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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TIM- CITY 7,rif v 4-1n. I MA DATE MJ/UIU' PERMIT# Pb n—00 t9D
JOBSITEADDRESS 43) VerM6,n+ Ay_ UL'YAIMOJilkI OWNER'S NAME Pe+t the yipso ' J
G O61
WNERAORESS 5(kyyt.Q TEL 5(MT)`6llk-1 VAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL-
PRINT .,/
CLEARLY NEW:❑ RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑+
APPLIANCES 1. FLOORS- - I BSM 1 2 3 4 5 6 7 8 9 ' 10 11 12 13 14
BOILER BOOSTER , i_ I
I I I I
CONVERSION BURNER � �— r
COOK STOVE
DIRECT VENT HEATER r I DRYER
FIREPLACE - _lIiIIr 11-1117_:__ ,I_
111111 FURNAC OR r la;
FURNACE 1 Ir
GENERATOR
GRILLE / 1 Hi )r,
INFRARED HEATER ,
LABORATORY COCKS
MAKEUP AIR UNIT i ,
f 1
OVEN I -1 „
POOL HEATER
ROOM/ROOF TOP UNIT EATER
1
TEST
111%
UNIT HEATER77 _
UNVENTED ROOM HEATER ' I-
II —11' _. ,
WATER
-
WATER HEATER OTHER =S _
eft-—fair--
1
INSURANCE COVERAGE
11 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
Qre LIABILITY INSURANCE POLICY p+ OTHER TYPE INDEMNITY ❑ BOND ❑
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 SIGNATURE
AGENT
SIGNATURE OF OWNER OR AGENT
3 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 complian with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. A'
b ere"
aPLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 ' SIGNATURE
CD MPU MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION O# 3281C PARTNERSHIP EP LLC❑#_
`D 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 N/A . EMAIL accountspayable@efwinslow.com
Leff A ,t
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. MIA:\ A 1,51. YV,,.,,,V,,,Y{.M,.,. J OSWJMY„NJ4.H0,
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...r---= l Department of Industrial Accidents
,_Ann w Office of Investigations •
t =1fr1- b 600 Washington Street
• -Iii— Boston,MA 02111 -
'*4w.104 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information E //��, 1 1 Please( Print Legibly �1�V
Name(Business/Orlg��anization/Individual): .c.wIAS1o ) YIV✓,'ancj 0t0_Vt✓vq, \calci(,
Address: $ KP crawl Cid d (�
City/State/Zip: Scum Ycrwich,i-tn NN- Phone#: `503- 399-11?CI D
Are you an employer?Check the appropriate box: Type of project(required): $ CV"
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
:.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. 0 We are a corporation and its ^lv
required.] officers have exercised their 10.0 Electrical repairs or additions 0
i.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§I(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13.0 Other t\�
comp. insurance required.] `V\
thy applicant that checks box ff 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.
tsurance Company Name: "-1 C.-LI-VOA 1e-10C.n C- _ C el,,valtVII
olicy#or Self-ins.Lie.#: I' a I A' . Expiration Date: I—( - aOl9
1b Site Address: 3 G4vn
v .,nvr•PJ#h � C(^23k I 1111 % City/State/Zip: Oar I lo7
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
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
Cup to$250.00 a da a ainst the violator. Be advised t I at a copy of this statement may be forwarded to the Office of
tvestigations the DIA for insure r - overage veri a,on.
do hereby certify un a ains a /penalties o p- jury that the information provided above is true and correct
ignat& • Date: (a' 31 i ao19 1�
hone#: t1j 3S'- 7M7%
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.Electrical Inspector 5.Plumbing Inspector `
6.Other
Contact Person: • Phone#: \
vuisic,Th X•
\ #