BLDG-19-000786 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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` = 1_RIC CITY ih�MA/+/N MA DATE 5 14 114 1 PERMIT#A-017-19-000;s
JOBSITE ADDRESS Spm P & OelO v t�OWNER'S NAME I (,aiI, G P uir 1
GOMEIR ADD,(2EESS IC6 V kW LQRf Ln WMS I- utrrNork TEL 5IDq`11 S 4)'3 (7 'FAX
TYPE OR OCCUttP�kANC((Y�TYPE 3 COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
PRINT �/
CLEARLY NEW:❑ RENOVATION:❑ " REPLACEMENT:L.'( PLANS SUBMITTED: YES❑ NOM
APPLIANCES 2 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 i12 f 13 14
BOILER I _ - - I.
I
BOOSTER --
CONVERSION BURNER
COOK STOVE
_ -
DIRECTVENT HEATER _ I i_ _,
DRYER i
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR �NS_ ah
GRILLE � ,�
m ._ ��. �_ S
INFRARED HEATER �
LABORATORY COCKS
MAKEUP AIR UNIT I 'd
OL IIIIll
POOOL HEATER ,_
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER M,M ,�
. WATER HE
OTHER TATER n T ,� _ ITT1- _i
_ I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES M NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY p+ 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
o Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
' SIGNATURE OF OWNER OR AGENT
j0 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
Li and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with all Pertinent provision of the
Massachusells State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE It 12298 SIGNATURE
MPI MGF❑ JP JGF❑ LPGI❑ CORPORATION D# 3281C PARTNERSHIP❑# ]LLC❑# I
CP COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
1/442 tr CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 1
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tP FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com
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Department of Industrial Accidents
1w_,9iili= I Office of Investigations
`°t= 600 Washington Street ,
IELL= Boston,MA 02111
vert!s.. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please(� Print Legibly
Name(Business/Organization/Individual): E C.w1,- t 0,. QL 6.un3 g lco.\-' C . 1e1(.
Address: Z. Qpotlydn C eQ_ a d
City/State/Zip_ Sou Son 'crv.'c,J(n NI"r Phone#: _SOS- 399.117C1— ----- -
Are�you an employer?Check the appropriate box: Type of project(required): IN%
XI 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 v
:.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 N.,-' —‘�
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers'comp.insurance_ 5. ❑ We area corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
t.❑ 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
tiny applicant that checks box 41 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.
tsurance Company Name: fTyp, C1ake—A l lfWU11(.12_ Cavyt"1/4.41
olicy#or Self-ins.Lie.#: I$a[ P'r •
'1 Expiration Date: 1-1 - anl9
,b Site Address:a3 Guyer-nein w.teJI-h /Ism/ Ct e3 Y11II City/State/Zip: marl to
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
rup to$250.00 a da a_ainst the violator. Be advised teat a copy of this statement may be forwarded to the Office of
tvestigations . the DIA for insura. .overage verij on.
do hereby certify un i penalties o p•jury that the information provided above is true and correct. •
i_ atuT:• 4 AL.. . � Date: la 1 act .
or
hone#: SIA314. 177g
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#:
t