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Home My WebLink AboutBLDG-19-001032 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITT 1 Y=F CITY YRfIY1 I MA DATE t.,_ t/Lt PERMIT#/Y.-- 17S 9-07/6 JOBSITEADDRESS 96 pPir1S 14 Rf► IOWNER'SNAME [Arai IZoMansan I G OWNER ADDRESS PO P ,,x tit ASL1lnum NA TEL 50% 2) 1c-12O'FAX TYPE OR 0 I J30- G. J ,_,,/ PRINT OCC PANCY COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL�7 CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NOD APPLIANCES 7 FLOORS-. I BSM ' 1 ' 2 3 I 4 5 I 6 I 7 ► 8 9 10 11 12 I 13 14 BOILER BOOSTER - - _ --- - — - - - -CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS - MAKEUP AIR UNIT OVEN r POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT r TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES D NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYD OTHER TYPE INDEMNITY El BOND ❑ 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the um Massachusetts General Laws,and that my signature on this permit application waives this requirement. • CHECK ONE ONLY: OWNER❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru nd accurate to the best of any knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be in corn ' nce with all Pertinent provision of the :Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - /®1 � q PLUMBER-GASFITTER NAME I STEPHEN A.WINSLOW LICENSE# 98 SIGNATURE""�'( 122 (17--4 MPD MGF❑ JP JGF❑ LPGI❑ CORPORATION0# 3281C PARTNERSHIP❑# LLC 0# 1. COMPANY NAME: EF WINSLOW PLUMBING&HEATING 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 Si' (It d 3 • Maa Al On, �.vnwrworrcww.vJ 4 r1NJJMb/lfOCat, Department of Industrial Accidents 1- _ �lil�_ i Office of Investigations I_`ai__ t 600 Washington Street , Boston, MA 02111 %,-- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C f Please Print Legibly Name(Business/Or/ng�anization/Individual): L.r•W Tits iot,J Citf,.yto . 0t0.�.,.q Calot, Address: g' Keoc6n cl.lae_ 11Y City/State/Zip: Sou kin `f ctirr-cs,{ n NPr Phone#: 508-399-1117C 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. ❑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_ 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. 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.❑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.] my applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. . -lomeowners 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: hYYo.a f-11/441/0) MM(ft Ce_ C0 kivi )licy#or Self-ins.Lic.#: I'3 .I Expiration Date: (--I - aOi9 rbSite Address:a3 Gnen1/4.0)-eeJ411 1 09‘e414 14 City/State/Zip: 0aoto7 ttach a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). inure 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 'up to$250.00 a da a:ainst the violator. Be advised to it a copy of this statement may be forwarded to the Office of ivestigations • the DIA for insura,— overage veri j on. do hereby certify un e ains a penalties o p•jury that the information provided above is true and correct. ignatt • Date: la'31 I aolif (� , hone#: S )%:35`1. 777g 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 (� 6.Other Contact Person: • Phone#: •