HomeMy WebLinkAboutBLDG-19-002016 t%A5 /
_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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t' CITY I (Uttou rff (Poor) I MA DATE ///O 1/ hi PERMIT# �i�D6r-/l—c° e/6n
JOBSITE ADDRESSI3 17-1-l517-L Cite-Ca I OWNER'S NAME 14j j15 go pgz g&JS I
GOWNER ADDRESS 5g,08 TEIibvir V—Zrq71FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL ED EDUCATIONAL 0 RESIDENTIAL[r
PRINT _
CLEARLY NEW:ID RENOVATION:0 REPLACEMENT:LJ PLANS SUBMITTED: YES ID NOD
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER I I.
CONVERSION BURNER j,
COOK STOVE \
DIRECT VENT HEATER _
DRYER _
FIREPLACE
FURNACE I _____t_ I Y
GRILLRATOR I�
FRYOLATOR i _ � � I
GENE
i i
E 1
INFRARED HEATER I
LABORATORY COCKS _
MAKEUP AIR UNIT
—POOL
POOL HEATER I I Ir LIT-
I
ROOM/SPACE HEATERII
I ROOF TOP UNIT p I
` TEST
1:::J UNIT HEATER __ I
a% UNVENTED ROOM HEATER p_
WATER HEATER
OTHER 111S
in:I_
I [ 1 1
INSURANCE COVERAGE
n I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑
MI IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
(So
LIABILITY INSURANCE POLICY 0OTHER 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.
CHECK ONE ONLY: OWNER 0 AGENT 0
�` 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
VO. and that all plumbing work and Installations performed under the permit issued for this application will be in compr ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 9
PLUMBER-GASFITTER NAME I STEPHEN A.WINSLOW I LICENSE# 12298 SIGNATURE
MP ID MGF❑ JP❑ JGF❑ LPG'❑ CORPORATION Q# 3281C PARTNERSHIP❑# LLC❑#
COMPANY NAME: EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH ! STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com 1
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w— Department of Industrial Accidents
1I_ V1= i Office of Investigations
is w`I=• 4 600 Washington Street
:: - Boston,MA 02111
I .4 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information C Please Print Legibly
Name (Business/Ortgl1anization/Individual): E.F•WIASI QL ...6tInj 2, 0tpc�,✓vq Cm,,, l,1(
Address: g' t&porin.1 (110.42-
City/State/Zip:
rdQZ (lk
City/State/Zip: Sour 'cnA,c, -tn SA- Phone#: 133- 399-1117C/
Are you an employer?Check the appropriate box: Type of project(required):
Xam a employer with -70 4. 0 I am a general contractor and I 6. 0 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 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. 0 We area 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.]
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.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation. /� �
isurance Company Name: CfY t..J CEJ Atte j ^f V rq i t Q Cq , �✓ty `
olicy#or Self-ins.Lic.#: OS as it
1 Expiration Date: j—I I* aOl9
tbSite Address:. 3 Grnev- t,,rea��h �i C4dQg !I City/State/Zip: O. '4 (o7
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 \ (�
f up to$250.00 a da a:ainst the violator. Be advised t rat a copy of this statement may be forwarded to the Office of Q\ t�\
ivestigations • the DIA'for insura - ;overage verif ar on. -
do hereby certify un , ve ains an,penalties o p jury that the information provided above is true and correct. 19,,_\ \(
ignatu =• Date: lal 31 I aO17
hone#: Sj, l-111`jr 7778 qii\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): k
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
0