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Home My WebLink AboutBLDG-19-001220 L aak1= CITY VoiMidl/+1-t'l MA DATEI 'M24/kr{'1 IPERMIT# *Oa /gad JOBSITE�� ADDRESS I N S D/1� Pr Ln Yd/.VI OJ4OWNER'S NAME 1 �tI GI(Ill (admen GOWN RADDRESS itMIITEL'SOi11S1'IS S IFAXI TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ID RESIDENTIAL PRINT �,/ CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:9 PLANS SUBMITTED: YESD NO❑+ APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER MOS CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE - GENERATOR GRILLE - INFRARED HEATER r LABORATORY COCKS - MAKEUP AIR UNIT OVEN ..�.�.. POOL HEATER -- _ -- ROOM ISPACE HEATER _ _ ROOF TOP UNIT TEST UNIT HEATER' _ _ _ UNVENTED ROOM HEATER WATER HEATER OTHER -- - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 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 0 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. LD CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT N I hereby certify that all of the details and Information I have submitted or entered regarding this application are true an ccurate to the best of my knowledge o and that all plumbing work and installations performed under the permit issued for this application will be In compile. with all Pertinent provision of the :Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 ` SIGNA URE �� t:23 to MPU MGF❑ JP ID JGF❑ LPG'ID CORPORATIONQ# 3281C PARTNERSHIP❑#I ILLC❑# COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE ra CITY SOUTH YARMOUTH STATE MA ZIP 02664 TELI,508-394-7778 V.11 FAX 508-394-8256 I CELL N/A EMAIL'accountspayable@efwinslow.com ' d) 4 t • M\ a,si V V......nsrmN....f 1.JL.JJf.YeogaveW w— Department of Industrial Accidents ai._, �=.�t Office of Investigations -_EIM 600 Washington Street _ Boston,MA 02111 '�`..` www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers kpplicant Information f' Please Print Legibly \Tame(Business/Organization/Individual): E. .w1 5i ow Ciu„y6' Lc,..,-. - Ce,lint. kddress: g &eoc&bi Circle_ Nd :ity/State/Zip: Sou Ain Irro,r,,,(-tn (•{A- Phone#: `5)8-3q4-1174 Ere you an employer?Check the appropriate box: Type of project(required): ------t j SV am a employer with 70 4. 0 I am a general contractor and I 6_❑New construction employees(fol a1�n T part-time).* have iced the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet._ 7. 9 Remodeling ship and have no employees These sub-contractors have 8. ❑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.❑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'camp. c. 152,§1(4),and we have no 12.9 Roof repairs (�\\ insurance required.]t employees. [No workers' "y comp.insurance required.] 13.0 Other iy applicant that checks bok R1 must also fill out the section below showing their workers'compensation policy information. nneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. m an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site brmation. urance Company Name: Ants,.—I t L1voA (,1rt nte_ C vvy icy#or Self-ins.Lic. 'I c�if: isa i A • Expiration Date: (' i — ?019 Site Address: c.(raryntn%jt.e th )t-4 i Cee31114 I'U City/State/Zip: COLI Qs? :ach a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a sup 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 ip 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 a estigations • the DIA for insura, - overage veri j on. J r hereby certify un • , penalties o rury that the information provided above is true and correct. Hato :• c — de. Date: (a. 1 a(7]' -- \ me#: SOVIT l`1. 7 97g , N , ,s kt cal Official use only. Do not write In this area,to be completed by city,or town official • • City or Town: Permit/License# M Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1 v� S.Otheri. Contact Person: • Phone#: \N P