HomeMy WebLinkAboutBLDG-19-000809 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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;TN zt CITY ?firm V }, 1 MA DATE''JL.t/ PERMIT#/Jl,06-1I'0 Q
JOBSITEADDRESSIS&R14 m. s he I0 (A' +I• I OWNER'S NAME I A,II he 4- Ri/n ke/'lnn 44
GOWNER ADDDDRR�EjSi t L . . N EISAS3Gr2.2'741 (FAX I
TYPE OR CUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NOD
APPLIANCES 7 FLOORS-' A 6SM ' 1 1 2 3 4 5 6 7 1 6 9 10 11 12 13 14
BOILER I I --
BOOSTER IIMINS_I _ _
CONVERSION BURNER I
I r -
COOK STOVE M -
DIRECT VENT HEATER Iiiiiui.
,I_ -
DRYER
FIREPLACE Ir__-
FRYOLATOR ;, -_
FURNACE AM 1`
GENERATOR
GRILLE M
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INFRARED HEATER ,
LABORATORY COCKS _ -
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER '
ROOF TOP UNIT
TEST Mill , . ,
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER S la MMI ___ — —
OTHER
INSURANCE 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 ❑
ra 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 ❑
-4- SIGNATURE OF OWNER OR AGENT
(J) I hereby certify that all of the details and Information I have submitted or entered regarding this application are true d accurate to the best of my knowledge
0 and that all plumbing work and Installations performed under the permit Issued for this application will be In compll a with all Pertinent provision of the
v Massachusetts State Plumbing Code and Chapter 142 of the General Laws. pia d
t...0 PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SI ATURE
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MP CI MGF❑ JP JGF❑ LPG'El CORPORATION EP 3281C PARTNERSHIP 04 ILLC❑# I
6' COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE I
CITY SOUTH YARMOUTH I STATE MA ZIP 02664 TEL I
FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com
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•..... Department of Industrial Accidents
1lca—(l Office of Investigations •'
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_ ` .600 Washington Street, . '
• _ . , Boston,MA 02111.
1/4 www.hass.gov/dia• I. ••
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� 1 Please Print Legibly
Name(Business/Organization/Individual): E.c.INtrs• IOW 00.M61✓tcl L i4c0.F✓) Calci(.
Address: S' Q..eoc sn C a . a d
-City/State/Zip: -Sou -'fcrv-v.,,t'1n NAc Phone #: - `508. 399.17751
Are you an employer?Check the appropriate box: Type of project(required):
Xam 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
:.0 I am a sole proprietor or partner- listed on the attached sheet.t 7. 9 Remodeling
ship and have no employees These sub-contractors have 8. 9 Demolition
working for me in any capacity. workers'comp.insurance. 9. 9 Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its
required.] officers have exercised their 10.9 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 12.9 Roof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13.0 Other
my applicant that checks boz#1 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. //�� � 11
isurance Company Name: fkylv,J l,,.,1 tLYUo-A J.,nfut(ACt Cl:StN•altVfy
olicy#or Self-ins.Lie.#: $a I A 9
1 Expiration Date: (-1 - aOi
)b Site Address: 3 C4,vv\c,n\Peoa� �1 C0.,e.31114t�I' City/State/Zip: 0,-)467
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 `
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
ivestigations the DIA for insura overage veri a.on.
do hereby certify un e ains a penalties o p•jury that the information provided above is true and correct. •
ignat& • Date: la) 31 I aO17
hone#: 5j)'d;3S`I r "Inb'
Official use only. Do not write In this area,to be completed by city,or town official •
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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
c_ i).
Contact Person: • Phone#:
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