HomeMy WebLinkAboutBLDG-19-002219 41i.
MASSACHUSETTS UNIFORM'APPLICATION FOR APERMIT TO PERFORM GAS FITTING WORK
Drr= d
Li 'cliii r. CITY r liG&S it- ji • K .- .. .. MA DATE/°'/•3-/f PERMIT#74,12.b.-/7-80614.17
JOBSITEADDRESS;,%( .3,�aikefry' Cize/a 1OWNER'S NAME'f/Ie;K 2/,"119 1
GOWNER ADDRESS •. e na ITF1'S� ES/,Z�Y,iFAXI
TYPE OR OCCUPANCY TYPE COMMERCIAL;,.] EDUCATIONAL[] RESIDENTIAL
PRINT
CLEARLY NEW:;LI RENOVATION:'«_I REPLACEMENT:Xi PLANS SUBMITTED: YESJ NOI,.J
APPLIANCES? FLOORS-. BSM 1 2 1 3 4 5 6 7 8 9 10 11 12 13 14
BOILER L-1.�_ ..IliJ.-..--- +--I__k.-i( .—J__-I_-1 - -
BOOSTER ,_-1,_�v� -.J1.--11.
_ - .
_ . . ..�l.�J,_�r---.1 f.. ....J,i�..1.i��._..�_J Ire.- �
CONVERSION BURNER C---11==1"11;---- '`---..1E-1.-.2.J.---1.=_ __.,.1._.._1- -1:.:2:11
_1
COOK STOVE 1. J _ a
DIRECT VENT HEATER i r 1: _-J i I I%.---•E---a
DRYER i I-,i' r _ J; . I._. .I+ _ I'- .1 _- t I r---J
FIREPLACE • I _ ` . IL`_. .1y.� t
_I_-, ,
FRYOLATOR f t _ ___ � - J' I. J" R
FURNACE t Ji _ ^;
' GENERATOR t� I• i .I ' i I' - I
GRILLE __ r--- I __! -. + _ .J -- I' _J' -'
INFRARED HEATER J _ I J l -I _ a-s `'; - I -i ti." t
LABORATORY COCKS 1._ I.__.. ' _ J .....i. I I ..._.
MAKEUPAIRUNIT f . _. - • L.._...I I _ ' 1 .,.-.f I - J
OVEN -I _ J .._.._I -_, --r
POOL HEATER _ .i' .J, i .... i i:a I. -- -
ROOMISPACE HEATER _ ' _.l- , _ -..
ROOF TOP UNIT ,' ? ! _ I _ C
TEST i ..__) ... I _ . ..
UNIT HEATER _.*-1:_ , -._J... J. t' [ f_I
UNVENTEDROOMHEATER p 1 ' . • I •1 I_I--I --1 ____ -- —! �c
WATER HEATER_. ............. --. . . ;_Vi; . Li._I _ . l.il 'ILL:i..�I _J' .._._1 _.__'�_..-1_._-. eb
OIHER:_._....__ ._...._.._ ._ . . ..Ia - I: ...... ......1; - f[-.r.. .....1..... I� ......iiJi ..._I.J
• !'....- .-1:- -- i;---- •• .. ..J. i! 1-it�J_.I-._1 i� —I
• i _--. i,._.. r._.._.,-._..-. .
+ I ' !. I .. _- 4_..__. J.____1__—J_J`i__�I!�:_�.I..�—J �Lj
r. j=ii•- — i i._. .1 i:_J.i1 1 i :1_J_.:J L.2.1.__ ._.I:__2
INSURANCE COVERAGE
I have a currentJlability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IJ NO I..
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY .,;.I OTHER TYPE INDEMNITY _„( BOND L J
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 I.,,( AGENT i_J
SIGNATURE OF OWNER OR AGENT •
I hereby certify that all of the details and Information I have submitted or entered regarding this application are • nd 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 co II ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '//��1,-240 '
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE#:12298.1
' GNATURedI"_
MP.. MGF„,J JP .j ;
JGF , _•
J LPGIJ CORPORATION•,±]#:3281c f PARTNERSHIP.,3# . ILLC „f#.,_ ...:!
COMPANY NAME: E F WINSLOW PLUMBING&HEATING J ADDRESS•8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE i- MA iZIPi02664TEL 5083947178
FAX'508 394 8256 I CELL N/A IEMAIL.eccountspayableonefwfnslow.com . .
. Lif &dly
I`kms i dDeprartmenof nderstiepj cat2
EA' .Iji= Office of Investigations
5, it;!} 600 WashingtorlS'tveeB
�..=-- c 1®stoat,liii 02111 ••
•
www.meareigov/e';e '
Workers'Con pemsation lansuiramce Affidavit: ,,dens/C®mtractoragiec cisonus/Pl armbers
Applicant Information I Please Print%epibfr .
•
Mauna(Business/Organization/Indivldual): E'c.winsIow Y(V,y61,r� Q ate VG, I?IC.
Address: ` Keot&an G4t? (J �_
City/State/Zip: Sou Fe‘ YCrw+c,,,�-i,1 (y� Phone#: SUS-39`I-1`I?V ' •
. � (�
Ire you an employer?Check the appropriate box: Type of project(required):
.rI am a employer with 70 4. 0 I am a general contractor and I 6. 0 New contraction \ `
,employees(hull and/or part-time).* have hired the sub-contractors
.0 I am a sole proprietor or partner- listed on the attached sheet.= 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 \Q,
[No workers'camp.insurance 5. 0 We are a corporation and its
required.] . • officers have exercised their 10.0 Electrical repairs or additions ,
.0 I ani ahomeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
• ..-----.....C1-73/4.c.... •
myself.[No workers'comp. 0.152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers'
comp,insurance required.] 13.0 Other
my applicant that checks bat ill must also Ell out the section below showing their workers'compensation policy Information.
iomeowners who submit this affidavit indicating they are doing alt work and then hire outside contractors must submit anew affidavit indicating such
bnttactop that checkthls box must attached an additional sheet showing the name of the sub-contractorggnd'their workers'comp.policy information.
tin an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
'formation.
surance Company Name: 11111 -.-3 C k 4& `moi Wilt el
alley#or Self-ins,Lie.#: ISaI A ani`)Ar
Date: t—[— ani
lb Site Address:�3 G iwnan ut-e o•-[ �y CC's Y'1 h7I City/State/Zip: Oa y 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 0.152 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
Nap to$250.00 a da a:ainst the violator. Be advised oat a copy of this statement may be forwarded to the Office of •
tvestigations. the DIA for insuraye= .overage veri a on. t
do hereby card um a)pains an,penalties o pe jury that the Information provided above is true and correct,
_ a !(� i _,. -.AL- Date: i`ol - I 10[
hone#: .Silt•MI• ?77g
Official use only. Do not write in this area,to be completed by city,or town official •
City or Town: Permit/License# {I�\
Issuing Authority(circle one): \
1.Board of Health 2.Building Department 3.Clty/Town Clerk 4.Electrical Inspector 5.PlumbingInspector d
6,Other \
Contact Person: Phone#: • Acct