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Home My WebLink AboutBLDG-18-007299 SZA MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK iM �g-zt CITY Vt�IIYIQ01-1 I MA DATEI 4 jj cb! 14 I PERMIT# /31-41-"/P00.127/ JOBSITE ADDRESS 1Z U Twit. AVe (OWNER'S NAME PAM MtPhre— GOWNER ADDRESS Sa,✓YLe ITEL 50fI5(6440 JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL Er PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:Cr PLANS SUBMITTED: YES❑ NOD APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - L I I i BOOSTER - . 1 -- CONVERSION BURNER i _er r r COOK STOVE , DIRECT VENT HEATER __ 1 u - - DRYER 7 __ FIREPLACE FRYOLATORY r r FURNACE GENERATOR i , GRILLE S 1M r l INFRARED HEATER LABORATORY COCKS _ r MAKEUP AIR UNIT l [. OVEN \� POOL HEATER - — 1 () ROOM ISPACE HEATER ROOF TOP UNIT I ,-lii 1 r TEST I UNIT HEATER r� UNVENTED ROOM HEATER A - , WATER HEATER OTHER [ `� ! _. ,E1 —_. I a CA INSURANCE CVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑ z.z. 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT N� 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 compli e with all Pertinent provision of the i :Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -Lc/12a o�ai✓ tPLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 • SIGNATURE MPD MGF❑ JP DI JGF❑ LPGI❑ CORPORATION❑+ # 3281C PARTNERSHIP a# LLC❑# COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE I CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 I FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com I The Commonwealth of Massachusetts e/ Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 ;�, www mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664. Phone#:508-394-7778 Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with 10 employees(full and/ 5. ❑Retail orpart-time).* 6. ❑RestaurantBar/EatingEstablishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. 0 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.❑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 Investigations of the DIA for insurance coverage verification. I do hereby cerci the aihs and nalties o j perjury that the information provided above is true and correct R/ r/ Signature: 'Y '` on.,o<�— Date: la (.31 I i / phone#:508-394.7778 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 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: ��- (� www.mass.gov/dia �`