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Home My WebLink AboutBLDG-19-001030 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING Sips_o -:W.11_-@7,1 CITY Yofinvi 4-k MA DATE 11flItW PERMIT#&Da--/7 0°/C&) IJOBSITEADDRESS 5ar11t k5 hdow OWNER'S NAME Me nt N{wealtr G OWER ADDRESS 17.a. 4P it R(6G11S �,OAd },fnflf TEy 50%39%chi S9 FAX OU TYPE OR OCCUPANCY TYPE COMMERCIAL': / EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑+ APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 18 [ 11 ' 12 13 14 BOILER I 1 BOOSTER CONVERSION BURNER _ _- _- COOK STOVE II1M_ - - DIRECTVENT HEATERDRYER FIREPLACE FRYOLATOR FURNACE r) GENERATOR - - GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ` I OVEN POOL HEATER A _ _-- _- - ROOM/SPACE HEATER ' L.m - ROOF TOP UNIT TEST UNIT HEATER I UNVENTED ROOM HEATER WATER HEATER OTHER �, r INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑ IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY CI 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 ❑ AGENT ❑ - 1 SIGNATURE OF OWNER OR AGENT (i-N I hereby certify that all of the details and Information I have submitted or entered regarding this application are tru 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) e with all Pertinent provision of the ;Massachusetts State Plumbing Coda and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNA URE ar AC) fy f— MPD MGF❑ JP JGF❑ LPGI❑ CORPORATION❑+ # 3281C PARTNERSHIP a# LLC❑# 0 r 1'f' COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE ? CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 1508-394-7778 tr FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com i A..4 /./. ` .f.../ff,.6Me ' Lff4. i., . l. a,Jsim.mffJ SLtr. Department of Industrial Accidents I RAM-ft Office of Investigations =;411' ; 600 Washington Street ' a Boston,MA 02111 .� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please(� Print Legibly Name(Business/Organization/Individual): EC.Wtp ..510 . �pI eithm . tt0.\1 `e.} [/1(. Address: g Geav, C:it City/State/Zip: Said '{crwr,,,(tn t-tpr Phone#: 5)8-39`1-777S1 Are you an employer?Check the appropriate box: Type of project(required): Kam a employer with 70 4. 0 I am a general contractor and I 6. 0 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. 0 Demolition working for me in any capacity. workers' comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions .❑ 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.] • my applicant that checks box N 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. //�� aswance Company Name: IklTh.s r kuhjo,I - liti t n C2 `n eU \,,t`j )licy#or Self-ins.Lice.^#: I S a 1 't Expiration Date: (—I — aoi9 )b Site Address: 3 Av%r l vbe J41- hf A. / C1 NI City/State/Zip: 0X-167 7 ttach a copy of the workers'compensation policy declaration page('showing the policy number and expiration date). ailure 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 Pup to$250.00 a da a ainst the violator. Be advised t t a copy of this statement may be forwarded to the Office of tvestigations the DIA for insura I-- overage veri a on. do hereby certify un • cdns . penalties o p jury that the information provided above is true and correct. _ i nat$T : Date: 101 1 aol. F hone#: 51 8:111. 7778 • TN • 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 Arm 6.Other ^`�J Contact Person: Phone#: • a