HomeMy WebLinkAboutBLDG-19-001447 . .t. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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• :?;="ki- CITY '_ 0.r, �1,(,z _Sea: MA DATE:02/31• _jay PERMIT# /9-Pb"t7- 7
JOBSITEADDRESS'S...D r $ ma„--- !OWNER'S NAME .iled biC'_tri19JtQte.2
GOWNER A.DDRESS �- - rTELQ2o t, zyFAX;,,_,______,__,.
TYPE OR
OCCUPANCY TYPE COMMERCIAL-- EDUCATIONAL , RESIDENTIALI
PRINT --
CLEARLY NEW:;,• RENOVATION::,Z;/ REPLACEMENT:! , PLANS SUBMITTED: YES! S NO1+, `1
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APPLIANCES 1 FLOORS-r BSM 1 2 3 4 5 6 7 6 9 11 12 13 14 ('�
13
V,
BOILER
BOOSTER _• _
CONVERSION BURNER _ �
COOK STOVE -. _. 1/4
DIRECT VENT HEATER
DRYER . . . .--
6 -. FIREPLACE
nit FRYOLATOR
pie FURNACE —
GENERATOR -. ..:
00 GRILLE
•� INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT :r
OVEN
POOL HEATER - - -
3 ROOM I SPACE HEATER
ROOF TOP UNIT
TEST .. . -._
UNIT HEATER
UNVENTED ROOM HEATER
OTHER :...._.. ..._ ..
-
. ' .. . . •
....__ _ . , . _ . ,.. .. _ . ...... . .... .. . . .. ... . . .— -. . . . .
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [i NO ..J
1
VI, I IF YOU CHECKED YES,PLEASE INDICATETHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
re
LIABIUTY INSURANCE POLICY £2? OTHER TYPE INDEMNITY BOND_„,
I OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
00 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
0- CHECK ONE ONLY: OWNER --' AGENT L„,+
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 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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. tri
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 i SIGNATURE/� rt lu
MPIMGFIL.: JP:, ' JGF;,.- LPG! ' CORPORATION i7
,+_ # 3281C...,"�PARTNERSHIP; .„#::„.... ____,. LLCI #'
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
.-Y _. Q9-3q4 . ... —
_ _ . .�..._. . --_-• i TEL 508.3947778
CITY SOUTH YARMOUTH STATE MA ZIP 02664, _•,__,y,
FAX 508-394-8256 ;CELL'NIA EMAIL accountspaLable@efwinslow.com
1-/?/HI S'v �3
M:6:.\ »..,., a.t....701.1...•.•0"6.6..
t =w= l Department of Industrial Accidents • •
j_ Office of Investigations
_ ij_c 600 Washington Street
�� _ Boston,MA 02111
ritar
www.mass.gov/dia •
•
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual : 6 C.�,� jj 41 J-1,ny, C se) 1e l( ,
) y\5 yV l r n 01✓k'I
Address: S. Q eeczan C;;i _
City/State/Zip: Sc..*in Yen's;, k, t-&Pr Phone#: 133- �q1-1'7'7St
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 1
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
:.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.
[No workers'comp. 9. ❑ Build ng addition
insurance 5. 0 We area corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
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,§1(4),and we have no 12.0 Roof repairs
insurance required.]t . employees. [No workers'
comp.insurance required.] 13.0 Other
thy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they am 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. n
tsurance Company Name: iA l j,,.) (` O Lie-4 ,l nytt,,u el Cy C
alley#or Self-ins.Lic.#: ]`3 o' t[ A' Expiration Date: (—[ - )019
)b 3 C Site Address:aAntncvf k,.•Pt_ b r C 111II
City/State/Zip: Oat;to
.ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
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 fate
Fup to$250.00 a day against the violator. Be advised thea copy of this statement may be forwarded to the Office of j
tvestigations( ie DIA for insuranoverage ver/arson. - 1kkf
1
do hereby certify un e t�s an penalties o jury that the information provided above is true and correct. ® `
ignatu
(((��J t Date: (1. i aok7
hone#: SUR 194. 777' - _ .- - - -
Official use only. Do not write in this area,lobe completed by city or town official \ C
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#: �,