HomeMy WebLinkAboutG-18-6831 ' r
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`:row c,, CITY : � �f Z�T MA DATE .
f
31 [ 1 PERMIT# figiierler,29 On/
JOBSITE ADDRESS!4-& 0OC//6 5e j 1519-71 _OWNER'S NAME 7:04-13 63 Qr •
.,-
GOWNER,IDDRESS ; S�j � TEL Cog en-'�IIFT FAXy •
TYPE OR OCCUPANCY TYPE COMMERCIAL•' EDUCATIONAL ,� RESIDENTIAL'
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:;,. � " 73L0 PLANS SUBMITTED: YES O NO:+;'
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER 1. _
I _
COOK STOVE .
DIRECT VENT HEATER _... -.
DRYER �. :.
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS_—
MAKEUP AIR UNIT
OVEN _
POOL HEATER •
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST .
UNIT HEATER _ C
UNVENTED ROOM HEATER
WATERHEATER._..._ _.. . .
OTHER . .. . . . ....
INSURANCE COVERAGE
I have a current liability insurance policy or.its substantial equivalent which meets the requirements of MGL.Ch.142 YES GnNO L..
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
L1ABIJTY INSURANCE POLICY OTHER TYPE INDEMNITY '. BONDS,,,,,: O
OWNER'S INSURANCE WAVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General I.zws,and that my signature on this permit application waives this requirement.
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CHECK ONE ONLY; OWNER AGENT i _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 tru: and 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 comylnce with ail Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
4
PLUMBER-GASFITTER NAME•STEPHEN A.WINSLOW LICENSE# 1229: SI NATUR
MP +_, MGFIL,r JP t JGF. LPGICORPORATION[,+_ #'32815 PARTNERSHIP',
COMPANY NAME::EF WINSLOW PLUMBING&HEATING r ADDRESS 8 REARDON CIRCLE
CITY g--OU--....----_ .._. _...._..___ .._..._-•-•---- -MA -•----. _ ._......---- ------ —%
THYARMOUTH STATE' ,ZIP 02664 ' TEL
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FAX!508-394-8256:CELL NIA EMAIL'accountspaaable�a efwinslow.ccom�w
Lea- �O !o'
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'c\ (I.Y rVIIMIWI.I...aifl. f Atafa ua..I.MJ...IJ
w= Department of Industrial Accidents 4 ..
t�tr`h�t ..
= nl_ ,, Office of Investigations •
c._.. t 600 Washington Street
-t--- ° Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
•
Applicant Information c ans.. Please Print Legibly
Name(Business/Organization/Individual): E•c• 0.. 'e/�Iu,y6 k., Qom, oto-,-,, Qtr.)t vl(.
Address: ' Kpocttvl C'itr i
City/State/Zip: Sc.,::1/4b-% `er:•-.c,,,i-t-, tAA. Phone#: 'VS- 399-MS/ '
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Are you an employer?Check the appropriate box:
, I am a employer with 7O 4. Type of project(required):
0 I am a general contractor and 1 6. ❑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: 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. Q\
[No workers'comp. insurance 5. 0 We are a corporation and its
9. ❑Building addition
required.] officers have exercised their 10.0 Electrical repairs or additions
t.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions \`�
myself.[No worker 'comp. c. 152,§1(4),and we have no 12.0 Roof repairs l\
insurance required.] r employees. [No workers' ithhhA`\
comp.insurance required.] 13.0 Other
thy applicant that checks box HI 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. EE
Isurance Company Name: Ant....3 Mc. t'0-A 'l�y`>21,
olicy#or Self-ins.Lie.#: ($al A-
ir�^ Expiration Date: (-1 — ;�(,)l
tb Site Address:a3 CLs.'lninc..vn w4ei. k ,� Ct,e t it (L
� City/State/Zip: O,)t-1 fob
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 against the violator. Be advised at a copy of this statement may be forwarded to the Office of • N. ;
rvestigations the DIA for insuraz}eeloverage verifaion.
do hereby certify un e t s''an llpenalties o pe jury that the information provided above is true and correct.
ienatu?e> tw
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✓✓ Date: 1�) 311 anti
hone#: STA 35`i - 777X . (�
Official use only. Do not write in this area,to be completed by city,or town official \A\
City or Town: • Permit/License#
......c;N‘.
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#:
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