HomeMy WebLinkAboutBLDG-19-001482 t, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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?'ti 4 CITY i . .- _ : MA DATEa_pittir PERMIT# /3406- 9 o%veZ
JOBSITE ADDRESS;i, , L a _ L„I OWNER'S NAME CQ rm an , Com/,-J e
G OWNER A.DDRESS 1
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TYPE OR OCCUPANCY TYPE COMMERCIAL' 1 EDUCATIONAL 7-,I RESIDENTIAL 1st--
PRINT
CLEARLY NEW::- RENOVATION:(,_r REPLACEMENT: _ .---**7 PLANS SUBMITTED: YES:I NO' •7
. - .: '
APPLIANCES 7 FLUOR:-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER •- _.
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COOK STOVE T T rt ., ._ ._-
`S DIRECT VENT HEATER .. . ,.- .
DRYER
FIREPLACE
DO FRYOLATOR
"•-• FURNACE —_. . _, .
GENERATOR _ . . .
I GRILLE
0 INFRARED HEATER
-
3 LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
t_. —
TEST -
UNIT HEATER
UNVENTED ROOM HEATER --
WATER HEATER,.__.-,- ,- • - - ,- .- _
INSURANCE COVERAGE
I have a current liability insulance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LS NO ';e1-1
c/) I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I,AA OTHER TYPE INDEMNITY ` BOND L
[---- OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
I Massachusetts General Laws,and that my signature on this permit application waives this requirement.
_ CHECK ONE ONLY: OWNER AGENT 0
a_ SIGNATURE OF OWNER OR AGENT
I hereby certify that all of tie details and Information I have submitted or entered regarding this application are truely=curia;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 a with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
._. _._.__.._..--__.._...._ _-__._.__., accurate
' PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW _ — LICENSE#' 12298 - / SIG A TURE
MPI,;. MGFI. I JP;,, JGFr.7 LPGI-- ?• CORPORATION # 3281C !PARTNERSHIP(•,,# _�^-__ LLC'_':# _W.a_ _1
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ,ADDRESS 8-REARDON CIRCLE
CITY 'SOUTH YARMOUTH InI STATE ,MA I ZIP 02664 '•- 'TEL,508394.1778_ - w My
FAX 508-394-8256 ;CELL N/A EMAIL'accountsopyable@efwinslow.com
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MIA .,.. ..... w,.,..»••.. ) .
w= Department of Industrial Accidents
1�:'>i�ira 1l Office of Investigations ` "' • I
sit. =lit=1y 600 Washington Street
':y i Boston,/WA 02111
svo• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Ortganization/Individual): EC. w') AjlG.,v a.;AntOtncc ,F t-�{c\'✓�6 C&t) ki( ,
Address: ' Ketchsn C,;raZ
City/State/Zip: Sc..: ' Yer .:„., l n Nrr Phone#: 533--3C{i--11331
Are you an employer?Check the appropriate box: • Type of project(required):
.41 am a employer with 70 4. 0 I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
:.0 1 am a sole proprietor or partner- listed on the attached sheet. : 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. ❑ We are a corporation and its
required.] officers have exercised their 10.0 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 12.0 Roof repairs
insurance required.]t . employees. [No workers'
13.0 Other
•
comp. insurance required.]
. lny applicant that checks box#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. ,,,
/� ,1
tsurance Company Name: �7'Y ,...7 lv L a- ((in fLy21 el C Gt \✓1y
olicy#or Self-ins.Lic.#: Y3 of I Expiration Date: (—I — ,)3 9 DRi
)b Site Address:.23 G3ewv c nl w.ec_ 41-% ,A�7 C e \4. IAA City/State/Zip: O,)4(c 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 t
f up to$250.00 a da a ainst the violator. Be advised tbtat a copy of this statement may be forwarded to the Office of
lvestigations the DIA for insurar�ee overage veri ayton.
do hereby certify un e is an penalties o pe jury that the information provided above is true and correct.
es_
iQnatu to Date: I%).) 2 i G'1 d \
hone#: ciy 3%`i - 7 7 n \ �N
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#: