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HomeMy WebLinkAboutBLDG-18-002996 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - �/ `?="1-f CITY Y(7t(tro 1 ( 7 nt.+) • MA DATELIII , I7 PERMIT# nrLnU/9 -Co A"�� JOBSITEADDRESSL3 ai n-{-loK, OWNER'S NAME�Ev intaunder .(jij1dt( 1 GOWNER ADDRESS 1 � , _._! 1. 1 l4I f_A ITEL3rl - J� TYPE OCCUPANCY TYPE COMMERCIAL° EDUCATIONAL J RESIDENTIAL CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES® NO +° APPLIANCES 7 FLOORS-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER r _ i ,'_- dl_ I. .- _ . -- BOOSTER r '1 . ' I ®I ._ • `I W CONVERSION BURNER 1-----71117— COOK STOVE DFIRECT VENT HEATER 11:1 'rvl. .T'� --- ( II L. I _ DRYER 1 h I.. 1 __ air— �l . FURNACE GENERATOR INFRARED HEATER GRILLE � • � o LABORATORY COCKS 111 MAKEUP AIR UNIT �aa _ OO � .. ' gin •i� i. ROOFOP UNIT 11111W111111-1111111111. = aim TEST I '1 UNIT HEATER 11•- = • IEROOM HEATER . �WATERHEATER s � ` _ OTHER — _ _ _ ��__�_a_i�I��®,�7�__ 11... . z-�-"sen a•�csmessz7®1 ��®��_�__�7�i�1 _• _ 11111111111111111111 I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L NO U 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY® BOND El 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 El AGENT El 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 an• -ccurate to the best of my knowledge end that all plumbing work and installations performed under the permit Issued for this application will be In compllan ith ell Pertinent provision of the Massachusetts State Plumbing Code end Chapter 142 of the General Laws. —/ PLUMBER-GASFITTERNAMEISTEPHENA.WINSLOW 1LICENSE# 12298 S GNA IIR MP[B MGF® JP© JGF® LPG'® CORPORATION 0# 32810 PARTNERSHIP0#=LLC[# COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE 9 CITY SOUTH YARMOUTH ._v j STATE MA ZIP 02664 TEL�508-394-7778._--_ _, ,___T-_• _ FAXI 508-394-8256 ,CELL WA EMAIL accountspayable@efwinslow.com • t�ff- � r-' q I • AThe Commonwealth of Massachusetts ii._uiVt= t Department of IndustrialAccidents • - =1H I= § 1 Congress Street,Suite 100 )7-411,i,_.= IL= Boston,MA 02114-2017 ; e;t www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. ^, Applicant Information Please Print Legibly I \1 Rs. 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.❑✓ I am a employer with 10 employees(full and/ 5. 0 Retail `C\T or part-time).* 6. ❑RestaurantBar/EatingEstablishment 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. 7. El Office and/or Sales(incl.real estate,auto,etc.) QtN. `1y Ki [No workers'comp.insurance required] 8. ❑Non-profit 3.0 We are a corporation and its officers have exercised 9. ❑Entertainment ‘%.,. ..„ their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]** 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees.[No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box#I 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 I City/State/Zip: CHESTNUT HILL,MA 02467 Policy#or Self-ins.Lic.#1 821AExp ration Date:01/01/201g 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 n 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 cert! the ayirs and enalties o perjury that the information provided above is true and correct,, Signature: ��l?4-. ,w - h i... Date: 1). /3/ t � Phone#:508-394-7778 _.. '< C Official use only. Do not write In this area,to be completed by city or town official City or Town: Permit/License# ( -..b. 14: Issuing hority 2.Buircle ode): FJ 1.Board of Health Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: `f\ www.mass.gov/dia �k• 3 I