HomeMy WebLinkAboutBLDG-19-000971 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WOR
s sdrr i.
_ �E
'M `
'MU CITY Ya0mU-)�oMA DATE Qt)1zi( l4S PERMIT#`�DG/7'100
G JOBSITEADDRESS ' An1f G5 beIOGr/ OWNER'S NAME AO 4049 Pkvi/tbi1e
OWNERADDRESS I IS Mo Chil air Loy Y01010,1-14 TEL 50$39aa419 FAX
TYPE OR OCC
PANCY TYPE COMMERC ❑ EDUCATIONAL❑ RESIDENTIALD
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:L„r PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 7 FLOORS-0 BSM 1 ' 2 ' 3 4 5 6 7 8 1 9 1 10 11 12 ' 13 14
BOILER -
BOOSTER - IIIIIIII♦IM_- - - -
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER _ _ _-
FIREPLACE -
FRYOLATOR
FURNACE -
GENERATOR I _
GRILLE
INFRARED HEATER, 1 _
LABORATORY COCKS i -
MAKEUP AIR UNIT
- -
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT • .
TEST
UNIT HEATER
UNVENTED ROOM HEATER ;.
WATER HEATER
OTHER F _ - SaS int
�
_ -
r INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ElNO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
i LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY ❑ BOND 0
' 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 ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are lru nd 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 comp ce with all Pertinent provision of the
cry :Massachusetts State Plumbing Code and Chapter 142 of the General Laws. w �� ,
C) PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATU RE
,v
MPI MGF❑ JP I: JGF❑ LPGI❑ CORPORATIONQ# 3281C PARTNERSHIP❑# (LLC❑#�
COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE I
`I'
CITY SOUTH YARMOUTH STATE MA ZIPI02664 TEL 508-394-7778
O ti
I--tp FAX 508.394-8256 CEL N/A EMAIL accountspeyable@efwinslow.com
di \ S.Est. VV/Innsn,,srn.ina,. VJ 41,/1401.11141../014/Calla
we Department of Industrial Accidents
to _; ritwiri= t Office of Investigations
?. i� 600 Washington Street
_ Boston,MA 02111
. `.fit www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information C /� Please(lPrint Legibly �\
Name(Business/0rPngtanization/Individual): E•r.W.r‘sIot,�J aMounq $. tit R\r Qe., ).iC.
Address: g Keotitvi eictiQ, a d
City/State/Zip: So,>N `fcrw-c,,,i-tn MA- Phone#: "SOS-3c19-11'1St
Are you an employer?Check the appropriate box: Type of project(required): •
'" I 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 T. 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 \ I NC\
[No workers'comp.insurance 5. 0 We are a corporation and its �{
required.] officers have exercised their 10.0 Electrical repairs or additions �C\
.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions p�
myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs \�
insurance required.]t employees.[No workers'
comp.insurance required.] 13.0 Other
my applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. •
-Iomeowners 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: PK-Md.) 601-1.10-)1 `{ !1 ftt el (Th h ty
,licy#or Self-ins.Lice(.#: I S a I 1 1 Expiration Date: I-1 - aOI9
tbSite Address:a3 GlnnewsnWfJill i Cher N I City/State/Zip: dar-Ito?
ttach a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date).
iilure 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
----11-\\I '
up to$250.00 a da a•ainst the violator. Be advised t r.t a copy of this statement may be forwarded to the Office of
tvestigations • the DIA for insura. - overage verij on.
do hereby certify un penalties o rug that the information provided above is true and correct
is atticDate: la I a01' J
�jg;3S 1• "I��b' \
II
hone#:
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#: