HomeMy WebLinkAboutBLDG-19-000831 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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t ?m k(-_F cr CITY I Ya fM L U 449‘ r MA DATE�'iLflL:� PERMIT it��-I Q'�d 7 I
JOBSITEADDRESSI Same ag (Innev,j, IOWNER'SNAME Chris Sm ti I
G QWNERADDDRee ILS ran klf YQ/encu I TEL 50Sh EqQ 1335IFAX1 I
TYPE OR (OCtuPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL '
PRINT ,�
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:EK PLANS SUBMITTED: YESD NOD
APPLIANCES 7 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILERL
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER __
FIREPLACE IIIl_
FRYOLATOR
FURNACE 1 _
GENERATOR l _1-
GRILLE MI
INFRARED HEATER a 5
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN ,
POOL HEATER ,
ROOM/SPACE HEATER _ - _
ROOF TOP UNIT M
TEST _ -
UNIT HEATER
E ED ERM HEATER
WA .1111111.,-
WATERR HEATER T
1OTHER 1.____., M� -IMI,IMM i
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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 El NO El
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.
CHECK ONE ONLY: OWNER ❑ AGENT❑
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 d accurate to the best of my knowledge
.4-, and that all plumbing work and installations performed under the permit Issued for ihls application will be In compli e with all Pertinent provision of the
(4 S . :Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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V PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 - SIGN TUBE
ill N, MP ID MGF❑ JP JGF0 LPG!El CORPORATIONQ# 3281C IPARTNERSHIP❑# LLC D#
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COMPANY NAME: EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE
= # CITY I SOUTH YARMOUTH I STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com I
. 1€6 60,
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L-:_-=•i= +DepartmentofIndustriaiAccidents <' .•.,
t = vi.�t Office of Investigations f
C f._}'l= ` 600 Washington Street . , .
Boston,MA 02111
.-t www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information G Please Print Legibly
Name(Business/Organization/Individual): E.c.WrnsIOW YtVe,.10.tr L '&0.1 ✓sq. Ce.} Tint.
Address: Z' &eoclan C)/ae. a d
City/State/Zip: Sou by `f crwk,,, -tn (-Or Phone#: "5J3. 3q4-11'7c
Are�you an employer?Check the appropriate box: _Type of project(required)•
iirl 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
:.0 I am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Remoderling
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.❑ 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.❑Other
thy 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.
ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation. //�� -- I [
isurance Company Name: AYl ...J Kit-tlo-A j_nstnint n ct Cc yny
olicy#or Self-ins.Lie.#: 18 a I AV • '1 Expiration Date: I—I — a01
9 \
rb Site Address:a3 �gryvwe lw2o 4t .A4-411 Che3� YIt NI City/State/Zip: O,44la7
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a N
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
f up to$250.00 a da a ainst the violator. Be advised t,at a copy of this statement may be forwarded to the Office of
ivestigations the DIA for insurar - •overage verif a,on. k"
do hereby certify an e ains a penalties o p-jury that the information provided above is true and correct. 4 .
ignattT • Date: Ial 311 aoi?• .
hone#: SI)11314• 7778
Official use only. Do not write in this area,to be completed by city,or town official. •
City or Town: Permit/License# ' \-t, .R
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#:
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