The URL can be used to link to this page

Home My WebLink AboutBLDG-19-0022150 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `:esatSys CITY -1 f}/LncuJ7i/Roe_r) I MA DATE /O//%b' I PERMIT# / J/tlTJ af4:9 JOBSITE ADDRESS SS' CROSS Sr .s ry f I OWNER'S NAME W/C//i¢p1Q 2.9044// r GOWNER ADDRESS I --5/Wil a ITEL SQS, p2.%3S' FAX TYPE OR OCCUPANCY TYPE COMMERCIAL DI EDUCATIONAL❑ RESIDENTIAL / PRINT CLEARLY NEW 0 RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES❑ NOEI APPLIANCES? FLOORS-, BSM 1 2 3 ' 4 5 ' 61718 9 10 11 12 13 14 BOILER I t I I I BOOSTER CONVERSION BURNER COOKSTOVE DIRECT VENT HEATER 1 ( , I DRYER L _FIREPLACE l FRYOLATOR i FURNACE I I . 1 {_ GENERATOR GRILLE I I i I INFRARED HEATER :, - � I. LABORATORY COCKS _ ,. _ AIR UNIT II , _ r OVEN �— 1r MAKEUP POOL HEATER •f ,_ 143441/414k ROOM/SPACEROOF TOP UNIT ;1 ir- __ I 1 TT �� r TEST / _ UNIT HEATER I_ UNVENTED ROOM HEATER ,i I WATER HEATER OTHER I I I I IS, INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑ O I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW dLIABILITY INSURANCE POLICY aOTHER TYPE INDEMNITY ❑ BOND ❑ 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 ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT ii I hereby certify that all of the details and information I have submitted or entered regarding this application are 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 co lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I STEPHEN A.WINSLOW I LICENSE# 1229 " /" SIGNATURE MP El MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION D# 3281C PARTNERSHIP❑# acD# COMPANY NAME: EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com I led- Go L3 eI.\ t..f. l_V......V....{.M..,. j laYJJYM..NJ{..W w_= Department of Industrial Accidents le=E] l= t Office of Investigations • _ I =1 r;= J 600 Washington Street =ii_I Boston,MA 02111 .3. * 47 , ;� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C I 1 Please Print Legibly Name(Business/Ortganization/Individual): E.c.Wir,S(C J QkJi'400 t� $ titat'✓vq, `e,, brit . Address: �eo rin ciao, d City/State/Zip: So,JY% 'crwe.,.,k'n NA- Phone#: '5O3- 399-11'7Se Are you an employer?Check the appropriate box: Type of project(required): jErl am a employer with "70 4. 0 I am a general contractor and I 6. 0 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 workingfor me in anycapacity. workers' comp.insurance. P tY• 9. 0 Building addition [No workers' comp.insurance 5. 0 We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] i.❑ 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' 13.0 Other comp.insurance required.] thy applicant that checks box 41 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 rformation. isurance Company Name: Art3.,..) r‘0hie."1 _Lin p(T2letCP_ \ q•,, t\rty olicy#or Self-ins. Lic.#: 1'3 al A Expiration Date: I—I — a0l9 )1)Site Address: 3 ConnMovtvreJ4h 0404i ChesknA MI City/State/Zip: Oa LI b7 ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). allure 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 a:ainst the violator. Be advised t r at a copy of this statement may be forwarded to the Office of Ivestigations , the DIA dor insura overage verif a on. do hereby certify un te'ains an'penalties o p• jury that the information provided above is true and correct. ignatu /K Date: (a' 31 I awl_ N hone#: 5)1:3114. 777g • " Official use only. Do not write in this area,to be completed by city.or town official • City or Town: Permit/License# C I 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#: