HomeMy WebLinkAboutBLDG-19-002321 MASSACHUSETTS UNIFORM'APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES IA NO U
N
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY+.1 OTHER TYPE INDEMNITY J BOND Li
•
OWNER'S INSURANCE WAIVER:lam 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 .�,.f AGENT i...
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 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 oomph with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. so ���h /
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PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW . 1 LICENSE# 12298 SIGNATURE
MP...a MGF:Li JP •,-] JGF::j LPG!_,j CORPORATION.,]#:3281C I PARTNERSHIP.,S# • . ]LLC j#.
COMPANY NAME: E F WINSLOW PLUMBING&HEATING (ADDRESS•8 REARDON CIRCLE J:
CITY SOUTH YARMOUTH J STATE!, MA 1 ZIP i 02664 {TEL`508 394 7778 _
FAX:5083948256 j CELU N/A I EMAIL'accountspakable@efwinslow.com _
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G Department o,j'dndasrfpeQJAccaraet
an 1 Office of havesk®'2lons
ta AK= ' 600 M shecak&ore Sired
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,ti,,� Boston,MA 02111 •
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Workers'CeMpensatieri 1131saan'mraee rt St davit IllaDiklers/Contractors/lEles elans/PktMbers
koplfcant Infformation Please Print Legibly
Name(Bustness/Orgsnlmtion/individual): E f.W S 1 OW OVsa6'etei 1 VI to-V,riq c9 l elt•
•Address: . Gordan eirt,I.2- . (J
City/State/Zip: Soo k'n l ...-n 14161- Phone#: 'SOB-599-11'7V . • '
Ire 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 I6• [�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 are a corporation and its
required.] • • officers have exercised their 10.0 Electrical repairs or additions
.0 I am ahomeowner doing all work , right of exemption per MOL 11.0 Plumbing repairs or additions ,
myseI No workers'comp. 0.152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
my applicant that checks bean must also Ell out the section below showing their workers'compensation policy information
fomeownera who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'antiactors thatcheckthls box must attached an additional sheet showing the name of thesub-contractors gad their workers'comp,policy information.
Int an employer that is providing workers'compensation insuranceformy employees Below is the policy and job site 1
rormatian. ,
suranceCompanyName: 11trtil+J (`kOho-A Ti• (Mtn uLsF In
•
rlicy#or Self-ins.Lie.#: ISal Expiration Date: I—] - aOI1
tbSite Address: 3 LClnnrWrnkreo-1h Atm) Crneslati- 11)7I City/State/Zip: Oa Li 67
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). •
ailuro to secure coverage as required under Section 25A of MOL a.152 can lead to the imposition of criminal penalties of a
se 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
nip to$250.00ada a:ainst the violator. Be advised t .t a copy of this statement may be fcrwarded to the Office of
tvestigations• the DIA for insurape: k overage yeti ca on. t
do hereby certify u ,e a airs an,penalties ojury that the information provided above is true and correct.
atu3=_ — I. . L Date. b. i aOO"
gond#: .SI .Th• 7778
Official use only. Do not write In this area,to be completed by elty,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
6.Other
Contact Person: Phone#: