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Home My WebLink AboutG-19-2174 - -=c k=,s clrY �(nrr�'tptl f)497a- I MA DATE�n1 (NLA PERMIT# fr G ft-cv0/ IV Jaa6Z�RESS . t .s 4 m, Jh,./ •WNER'SNAME I Kiel lin (/o Vet I GOWNERADDRESS r, a , 4411TE19OLW242.30OO (FAX TYPE OR 114 OCCUPANCY TYPE COMMERCIAL 1! •UCATION ❑ RESIDENTIAL,,_: PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ NOD APPLIANCES 1 FLOORS--• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 CONVERSION BURNERW. 5 P,M P a aE BOILER ®�_ _ ®® Ea BOOSTER ®®®®® - - COOK STOVE MIS s!MN SIM 5555®®ISM � DIRECT VENT HEATER ®�EMENI® �- DRYER Ir FIREPLACE FRYOLATOR 5,ME,�,�®, I III II 1111 FURNACE NM a ENS'M GENERATOR �_aw ME IIII GRILLE ass®s -- LABORINFRARED HEATER � ®� II 0 COCKS � , MAKEUP AIR UNIT �ME®,�®� LABORATORY OVEN Mil POOL HEATER 111111111111111111111111111111_ ®:I_ ROOM I SPACE HEATER MIAM,w,_.w®E®MM® ROOFTOP UNIT sass M w,®_ IS a �- UNIT HEATER _®la ®, TEST �(�� 1111 �. UNVENTED ROOM HEATER �� WATER EATER ®®M® _ OTHER _ �,�.®.�,®SsSflas -- ME Pailli :a_a al,i■■S liMall M_®MUMS a MIa EON lawM_ ®. as NM Mil INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ID OTHER TYPE INDEMNITY❑ BOND ❑ J1 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. t ) ezi CHECK ONE ONLY: OWNER❑ ,AGENT ID c) SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tt :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 nce with ell Pertinent provision of the 1/-1 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. p / / . PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MP EI MGF❑ JP JGF❑ LPGI❑ CORPORATION❑+ # 3281C PARTNERSHIP❑# LLC❑#I I S.� COMPANY NAME. EF WINSLOW PLUMBING&HEATING ADDRESS I 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 ITELI508-394.7778 I FAX 508-394-8256 CELL N/A (EMAIL accountspayablenaefwinslow.com (A off - • Off\ a I64 V17IIMIIyISInfai6M IV III Mousima MJ44W cw=_ t Department of Industrial Accidents =a'n1= Office of Investigations 'n_;:ela` 600 Washington Street Boston,MA 02111 %`-.7,-sk www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers kpplicant Information Please Print Legibly \lame(Business/Organization/Individual): E.C.wins'0ty 0tt,iy10'ynri A. t1tca Qs, lel C• \ddress: $ Goatin elate e :ity/State/Zip: Sou Ain `fcr,,,,c,,,-t,, t• Pc Phone#: SUE-399.ititj Nrre you an employer?Check the appropriate box: Type of project(required): I am a employer with 10 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 0 I am a sole proprietor or partner- listed on the attached sheet.t 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 11.0 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' comp.insurance required.] 13.9 Other y applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • ,meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. Pet an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 9rmation. urance Company Name: �Yj p„y t%A-uoA �I f n te_ C lily icy#or Self-ins.Lie.^#: 'IS a l Ar . Expiration Date: (-1 -- aol9 I Site Address: �e.nrwmcr fa-14h AG-41 C,e3. `, NI City/State/Zip: OaL1 to 7 :ach a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a :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 )".0 rp to$250.00 a da a ainst the violator. Be advised t..t a copy of this statement may be forwarded to the Office of estigations the DIA¢or nsura overage vert a on. a hereby certify an , penalties o p•jury that the information provided above is true and correct. natuT. C I- Date: 1a 1 2t01' N. )11e#: 9jL 35y• 7978 O 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 S.Other Contact Person: • Phone#: