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Home My WebLink AboutG-19-243 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK W t CITY 1!1(MVJ-k f (.pY) 1 MA DATE '1 n. i 4 I PERMIT#/D6'-/7—"d9' JOBSITEADDRESS ljq I4dti61 ROAII IOWNER'SNAME Inc CQ &ena ? 1 G PRIOWNER DDRESSJV% INfb:1uqIS fp/M RetACI ITE Oc6l"159Z"19 FAX TYPENOTIT SOC UPA CYrI fPE 1 C6MIv1Ef2aAL❑ EDUCATIONAL❑ RESIDENTIAL CLEARLY NEW: RENOVATION:❑ REPLACEMENT:EK PLANS SUBMITTED: YES❑ NOD APPLIANCES 2 FLOORS-. BSM 1 2 3 4 5 6 r 7 8 _ 9 1 10 I 11 12 13 14 BOILER r 11 _ I I BOOSTER J 1 CONVERSION BURNER COOK STOVE J DIRECT VENT HEATER IF l I l,- DRYER MEM. FIREPLACE _ FRYOLATOR lr FURNACE GENERATOR i i GRILLE INFRARED HEATER 1,, LABORATORY COCKS 1 MAKEUP AIR UNIT - 'i - 1 OVEN is 0 \p POOL HEATER ROOF TOP UNIT -i A. ROOM/SPACE HEATER TEST UNIT HEATER , ,, I_ N UNVENTED ROOM HEATER WATER HEATER MOW OTHER r '',�, , 1_ _L r l - INSURANCEI COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑+ OTHER TYPE INDEMNITY ❑ BOND ❑ `,bOOWNER'S INSURANCE WAIVER:lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the v_) Massachusetts General Laws,and that my signature on this permit application waives this requirement. bo CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are tru 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 compl nce with ell Pertinent provision of the • . Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' PLUMBER-GASFITTER NAME STEPHEN A,WINSLOW LICENSE# 12298 S NATURE --6 MP ID MGF❑ JP JGF❑ LPG'El CORPORATION D# 3281C PARTNERSHIP❑# LLC D# COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE I CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 J FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com I 4,0 3 \ a,. _-vnw..vu.r a.....n J aa.uew..n.ww.. Department of Industrial Accidents 1= • Office of Investigations t=;n_ % 600 Washington Street 74111-7Boston,MA 02111 %II.;Iwww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information //�� 1 Ple(asse Print Legibly Name(Business/Origanization/Individual): I. .Wt„SI0„i, `IIJN,birM� $. Ot0.F✓xq, \e•, Irl(. Address: 3 (�et c&t,n CitraQ, d City/State/Zip: Souk Ycrwc,.,[4.1 NAr Phone#: x508- 394-1117x1 Are you an employer?Check the appropriate box: Type of project(required): 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 :.❑ 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. ❑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 required.] officers have exercised their 10.❑Electrical repairs or additions 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 itI 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. //�� I tsurance Company Name: Ar' m..,-1 t1 a#V4'A 1-'futuu!tCP_ \(� elnr chill olicy#or Self-ins.Lic.#: isa I A Expiration Date: i—1 — a0i9 ]b Site Address:.23 GNv 1/4P-ea-Min Chea 1411 City/State/Zip: Oa LI lo7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 3 allure 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 Fup to$250.00 a da a ainst the violator. Be advised t..t a copy of this statement may be forwarded to the Office of tvestigations the DIA for insura -- overage veri a on. Nti do hereby certify un le ains a r penalties o p• jury that the information provided above is true and correct ienatu : Date: (x13112:017 I hone#: SUB:311/4I• 1778 _, Official use only. Do not write in this area,to be completed by city or town official • (p�� • City or Town: Permit/License# Issuing Authority(circle one): - Si \\ \A 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other . Contact Person: Phone#: *