HomeMy WebLinkAboutBLDG-19-002147 'Are f
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'at WV. g CITY YAIM71Utin MA OATEN-ftnl PERMIT# /h//XT/7—Wgi 7
OBSITEADDRESSI461 I.&5� Yat/r ic/cJ f 1, QLLr OWNER'S NAME Thg/Qp 5 Al/rl(L y
GYaIntal+{, 026
OWNER ADDRESS • . ! /% • a 0, .. TEL SQ$39$0003 IFMII I
TYPE OR OCCUPANCY TYPE COMMERCIALD EDUCATIONAL❑ RESIDENTIALO'
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:tar PLANS SUBMITTED: YES❑ NOD
APPLIANCES 7 FLOORS— BSM 1 1 J 2 1 3 I 4 I 5 1. 6 I 7 I 8 j 9 J 10 I 11 j 12 13 14
BOILER
BOOSTER
CONVERSION BURNER • '
COOK STOVE _ _ -_ — - -_ -
DIRECT VENT HEATER + r+
DRYER _
FIREPLACE .
FRYOLATOR
FURNACE L
GENERATOR
_ GRILLE
INFRARED HEATER, — .._ _
LABORATORY COCKS
' MAKEUP AIR UNIT T
OVENI
POOL HEATER
ROOM!SPACEHEATER
ROOF TOP UNIT
TEST l '
UNIT HEATER -
UNVENTED ROOM HEATER
WATER HEATER
OTHER1
, . - - --
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 Q 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 -
Jn.-. Massachusetts General Laws,and that my signature on this permit application waives this requirement.
a.In ^V
t,`pir:In CHECK ONE ONLY: OWNER CI AGENT
apt SIGNATURE OF OWNER OR AGENT
US,'C I hereby certify that all of the details and Information I have submitted or entered regarding this application are tru a d accurate to the best of my knowledge
V and that all plumbing work and Installations performed under the permit Issued for this application will be In comp e with all Pertinent provision of the
`..T. Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298IC* SIG ATUR'-
MPU MGF❑ JP JGF❑ LPGI❑ _ CORPORATION❑+ # 3281C PARTNERSHIP❑# I LLC 0#I I
COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESSI 8 REARDON CIRCLE I
CITY SOUTH YARMOUTH STATE MA ZIP 02664 ITEL 508-394-7778 I
FAX 508-394-8256 I CELL N/A EMAIL accountspayable@efwinslow.com
ail Lic‘
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Department of Industrial Accidents
_ �j'Et ' •• • , :. • Office of Investigations 4,14:, r .,_2 ;
_;411 ,600 Washington Street
—is Bost• on,MA 01111 '' '
•1`�` �, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
tpplicant Information C f' Please Print Legibly
Jame(Business/Orgganizationfndividual): E .Wt�1OW Ylt,w�by.� g 0{R�l, Ce;, ]111.
\ddress: $' Keoadtvl C.Irtle_ Q d
My/State/Zip: Sou len ycrw.o.. in (-IA- Phone#: NA-399-1"17St
NIre you an employer?Check the appropriate box: Type of project(required):
am a employer with 70 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
❑ I am a sole proprietor or partner- listed on the attached sheet.; 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.9 Roof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13.0 Other
iy applicant that checks boie#1 must also fill out the section below showing their workers'compensation policy information.
•
ameowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
man employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site
'ormation.
mance Company Name: PrrTh..../ t-IJ +o_1 2�to/tin r kety
icy#or Self-ins.Lie.#: I$a I A- Expiration Date: (—I — aol9
Site Address:ai Gsrv,n cwl, eo.I411 AR/ CFe3 171 City/State/Zip: Da'-I to?
: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
e 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
ip to$250.00 a da a_ainst the violator. Be advised ti.t a copy of this statement may be forwarded to the Office of
estigations • the DIAfor insural - overage veil on. it
y' "'
•
hereby certify un a sins a penalties o 'jury that the information provided above is true and correct. ' ,v
Hato? Date: la)31 aot7 �
me#: 51)1.3S'1• 7975 I
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 \
5.Other
Contact Person: • Phone#:
e