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Home My WebLink AboutBLDG-19-002126 sir- 'fa triad telt CITY Yafrne it4 I MA DATER/man PERMIT#/OO'7/' QM 6 JOBSITEADDRESS SNPYIC OWNER'SNAMEI Thnmms (.lay#-OA I G OWNER ADDRESS y ((AP5.1-art Q J w/S�' YA/MOufITEII S0c,6400/O IFAXI I • TYPE OR OOCCUI� YTYPE COMMERCIAL❑ EDUCA L❑ RESIDENTIALIr PRINT CLEARLY NEW:❑ RENOVATION:ID REPLACEMENT: PLANS SUBMITTED: YES❑ NOEJ APPLIANCES? FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER SWIM CONVERSION BURNER COOK STOVE . _ DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR MOM GRILLE INFRARED HEATER • LABORATORY COCKS _ . MAKEUP AIR UNIT �f OVEN POOL HEATER ROOMISPACEHEATER ROOF TOP UNIT TEST 7 UNIT HEATER UNVENTED ROOM HEATER WATER jEATER NPR 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 ❑ IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ BOND ❑ 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. .-rAa Q CHECK ONE ONLY: OWNER 0 AGENT ❑ cr tow SIGNATURE OF OWNER OR AGENT rt., - I hereby certify that all of the details and Information I have submitted or entered regarding this application are tru and accurate to the best of my knowledge e�.•��._, and that all plumbing work and Installations performed under the permit Issued for this application will be In comp' nce with all Pertinent provision of the �' LP. '•Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws. e'' � PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIG ATURE N- MPO MGF❑ JP JGF❑ LPGI❑ CORPORATIONQ# 3281C PARTNERSHIP❑#)ILLC❑#I COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESSI8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 ITEL I 508-394-7778 I FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwlnslow.com iev (off 3 • • \ a in. 0-V/IN/W/fI/lNt6I6'j 1/a Y./J.n.n~IL SIJ p.k._ Department oflnditstrial Accidents o:moi;VI ,' ,. , efface of Investigations ,I iMita ;i`� ) • 600 Washington Street. • "Boston,IIIA 02111• ` • 't • 1 www.n►ass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers applicant Information c Please Print Legibly 'lame(Business/Organization/Individual): a.c.WifS10w Y1�„yI0' $- t0.\.4q, Qs) [fit. kddress: 3 Qpodw ClraP.— d -2ity/State/Zip: Soo kn Yorw.ir,(i., MA' Phone#: GSM-399-777x1 (rre you an employer?Check the appropriate box: Type of project(required): I 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 ❑ I am a sole proprietor or partner- listed on the attached sheet.i 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working forme in any capacity. workers' comp. insurance. 9. 9 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 am a homeowner doing all work right of exemption per MGL 11.9 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.0 Other ry applicant that checks box#1 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. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. in an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site brmatlon. //�� ff urance Company Name: �lr{f1v � 1 v#alt_ a_nstect n t_p_ cmM� icy#or Self-ins.Lie.#: $a Expiration Date: (-1 - a019 SiteAddress:a3 rvsanwen-Iftl_ ,4*-e1 Cc'eJAndl. AiU City/State/Zip: 004 :ach a copy of the workers'compensation policy declaration page Mowing 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 :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 ap 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 ----"\- estigations the DIA for insura. - overage vert a: on. 7 hereby certify un • e ains a penalties o p•july drat the information provided above is true and correct. • '31.1. `` nattc� .• _ (� ` • •t ; iir Date: (a i a01' \ (b (1 • me#: .lY 3I1. 777�' 1 • a\ , Official use only. Do not write In this area,to be completed by city,or town official • (may • City or Town: Pennit/License# • \ C.:%.-1::\ issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Cv �\ 5.Other \ Contact Person: • Phone#: (\ t