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Home My WebLink AboutBLDG-19-002216 art IA Urn u-H \ I MA DATEE1tRIL'* PERM�IT# k/�/ 42.c; r• lo J � 8� ' J SITE RESSI S O 19(e S Kt P 4-YafMOU�I. I OWNER'S NAME TPEi 6GuADD G OWNER ADDRESS I SG(YIP I TE 0.friSaatl I FAX ,.,-,/ TYPE OR OCCUPANCY TYPE COMMERCIALQ EDUCAT L RESIDENTIAL PRINT PLANS SUBMITTED: YESO NODCLEARLY NEW:Q RENOVATION:❑ REPLACEMENT: APPLIANCES 1 FLOORS-' I BSM 1 2 3 4 5 6 7 B 9 1011 12 13 14 BOILER I J- - NMI ISM BOOSTER — CONVERSION BURNER COOK STOVE — DIRECT VENT HEATERt. — DRYER FIREPLACE FRYOLATOR FURNACE J GENERATOR GRILLE INFRARED HEATER __ _. ,- LABORATORY COCKS ® MAKEUP AIR UNIT _ lill;IS il OVENIIIIII S ._. POOL HEATER . _ _ Nit__ ROOM I SPACE HEATER ROOF TOP UNIT Sim.. TEST - UNIT HEATER __ UNVENTED ROOM HEATER WATER-EATER 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 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW Q LIABILITY INSURANCE POLICY 9 OTHER TYPE INDEMNITY 0 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. J CHECK ONE ONLY: OWNER Q AGENT 0 SIGNATURE OF OWNER OR AGENT °._J I hereby certify that all of the details and Information I have submitted or entered regarding this application are true a 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 compliar$$with all Pertinent provisiotkQf the •Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ar p1i OP PLUMBER-GASFITTER NAMEI STEPHEN A.WINSLOW ILICENSE# 12298 , SIGNATURE, MC] MGFQ JPQ JGFQ LPGIQ CORPORATION DI 1PARTNERSHIPDtI ILLCO#N C1:3 s COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE d_ CITY I SOUTH YARMOUTH I STATE In ZIPI 02664 ITEL 508-394-7778 FAX)508-394-8256 I CELL NIA EMAILI accountspayable(7a,efivinslow.com MCIA ase- •-•e sys*Errs,rouses Yr uiwoese ssh.mssa .. . _ i "— * _ Department of Industrial Accidents • • =;�1_ ^ Office oflnvesti ations �;_;� 600 Washington Street 1 • Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers licant Information Please Print Le.ibl arne(Business/Organization/Individual): E e'.Wry'QW eiti� b • g a1' e ity/State/Zip: a 1in yiin Phone#:__U8-39y-nfl �you an employer?Check the appropriate box: Y 'am a employer with "70 4. 0 I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6' ❑New construction 7. ❑Remodel ng I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub-contractors have working for me in any capacity, workers'comp.insurance. 8' Demolition [No workers'comp.insurance 5. 0 We are a corporation and its 10.0 Building repairsn required.] officers have exercised their Electrical or additions I I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[N6 workers'comp. c. 152, ees4[ and we have no 12.0 Roof repairs insurance required.]t em P Y [No workers' comp,insurance required.] 13.0 Other pplicant that checks box NI must also fill out the section below showing their workers'compensation policy information. :owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tctors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. zn employer that is providing workers'compensation insurance for my employees. Below is the policy and job site nation. nce Company Name: jl!tsx.4 tku veA T #or Self-ins.Lie.#: l$a I A Expiration Date: (—I- aOiq te Address:_ v,-ea( , C '' •City/State/Zip: t a copy of the workers'compensation. policy declaration t page OM ingpolicy theumber and ( expiration ate). z to secure coverage as required under Section 25A of MGL c. 152can lead to the imposition of criminal penalties of a _ 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 o$250.00 a da a:ainst the violator. Be advised t r.t a copy of this statement may be forwarded to the Office of gations • the DIA for insure, - overage veri j on. )reby certify un penalties o ray that the information provided above is true and correct. � Date: I . 1 a� T: aul. 7: 1 • 797; :gal use only. Do not write in this area,to be completed by city or town official • (l or Town: ng Authority(circle one); Permit/License# � %N.1 iard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector her act Person: Phone#:_______________ I e eI