HomeMy WebLinkAboutBLDG-19-001107 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY lawn O v)4-In I MA DATE Ilifi7hj rAl PERMIT#®Jf' /f-1/o 7
JOBSITEADDRESS' Sanit M5 {pick/ OWNER'S NAME tt/ LLI?I- U115Z.4tr
GOWNERADD ESS q h r� f ; r, ,/ I k TEL 96f 3`!N GS& (FAX
TYPE OR M1\ 016'1
PRINTOCCUPANCY T PE COMMERCIAL❑ EDUCATIONAL, ❑ RESIDENTIALE
CLEARLY NEW:0 RENOVATION:El REPLACEMENT:EUCPLANS SUBMITTED: YES❑ NOD
APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 773
BOOSTER / L
-
CONVERSION BURNER -_
COOK STOVE
DIRECT VENT HEATER aMINS -
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
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UNVENTED ROOM HEATER _
WATER HEATER
OTHER r s
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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 ID OTHER TYPE INDEMNITY 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 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.p 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 complla with all Pertinent provision of the
•Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r
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PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 t • SIGNAT R��E
V MPD MGF❑ JP ED JGF❑ LPGI❑ CORPORATION❑+ # 3281C PARTNERSHIP❑# LLC❑#
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= COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS I 8 REARDON CIRCLE
c CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
4– FAX 508-394-8256 CELL N/A (EMAIL accountspayable agefwinslow.com
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SsIA a in. late,MINIM rrcw..a•J ••awunw..r...u•..w
=%E ' Department of Industrial Accidents ,tir
I,,,,_a —, Office of Investigations
C.WIVE''11 600 Washington Street
_ Boston,MA 02111 •
�1•.... - www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information //�� Please(� Print Legibly
Name(Business/Organization/Individual): E•F•t�lt ,r slow eSi l gI `lui. 0t0- e, jell'•
Address: g &eochn Cartxo_
City/State/Zip: Sas Son `f cre.•c,,Atn NAr Phone#: "OE-399-1174
Are you an employer?Check the appropriate box: _
Type of project(required):-
Xam a employer with- 70- -- -4.-❑ I ani 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. ❑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' 13.9 Other
comp.insurance required.]
my applicant that checks box MI must also fill out the section below showing their workers'compensation policy information. .
-loineowners 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. ,,,,
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isurance Company Name: f rrri l t i o-A tc.rcet(p_ \n t vvi
alicy#or Self-ins.Lic.#: OS al P •v
f ''11 Expiration Date: (-1 - 30i9
/
Ib Site Address:e23 �,rea�t1) /SM J C6Z.A l-l• 1f7W City/State/Zip: 0,-Y4 7
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
'up to$250.00 a da a ainst the violator. Be advised hat a copy of this statement may be forwarded to the Office of
tvestigations the DIA for insurageE' overage yen a, on.
do hereby certify un ' e ains''a II penalties o p•jury that the information provided above is true and correct.
ignat&t Date: Ia)31 1 aaoll \
hone#: S1)1:314. '1978 \
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
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Contact Person: •• Phone#: \"
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