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HomeMy WebLinkAboutBLDG-19-002329 rE-5ttnn :Wgr.jr CITY V//lftH' I MA DATEITTC1 PERMIT#-. }bs P5A? JOBSITEADDRESS'IO_t t.t A4I,e.M YAltniq ,kIOWNER'SNAMEIMarlefkiwkWerAnaek4i I G0,404a ITEtISO$344`11Sq IFAx� OWNER ADDRESS I cum TYPE OR . OCCUPANCY TYPE COMMERCIALE' EDUCATI L RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES© NOD APPLIANCES 1 FLOORS--r 1 BSM 1 2 1 3 ) 4 5 6 7 6 9 10 11 12 13 14 BOILER -- _ 11. a1. _— BOOSTER BOOSTER CONVERSION BURNER __ COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR , GRILLE INFRARED HEATER LABORATORY COCKS ._ MAKEUP AIR UNIT OVEN POOL HEATER . _ _ ROOM/SPACE HEATERmi r -' """'�'� ROOF TOP UNIT -- _. - TEST UNIT HEATER UNVENTED ROOM HEATER WATERH TER OTHER — _ . - - • INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO Q I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0 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 Q 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 true a 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 compile with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. D JQ.../..4.,.../ PLUMBER-GASFITTERNAME'STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE tilCG6`^ \MPQ MGFQ JP0 JGFQLPG'Q CORPORATION Q#13281C IPARTNERSHIP©#1 ILLCD#I Cr r'^ i . COMPANY NAME'EF WINSLOW PLUMBING&HEATING ADDRESS'8 REARDON CIRCLE W $ a CITY SOUTH YARMOUTH I STATE MA ZIP'02664 'TEL'508-394-7778 I FAX 506.394-8256 I CELL N/A EMAILaccounts a able efwInslow.com I . : Cir /f • 3 Maars.. yVIIMIn,:•rl.."M.J uawuuw•r•u..•ru 1 _—r= / Department oflndtastrialAccidents _: t1/ i. :.1_ Office of Investigations —11 1Y1— 600 Washington Street • '., — Boston,MA 02111 www.fnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers licant Information Please Print Le'ibl ame(BusinessOrganizationIndividual): E•�.Wtns'OW eluoJb- 0.1 . e. int. ddress: 1 1 •orlon :1 i P— ity/State/Zip: co iin Phone#: %)3-3 9-n'A you an employer?Check the appropriate box: r-1am a employer with 70 4. [DI arir a general contractor and I Type of project(required): ] employees(full and/or part-time)* have hired the sub-contractors 6. 9 New constructiont 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. 0 Demolition working for me in any capacity, workers'comp.insurance. [No workers'comp.insurance 5. 0 We are a corporation and its 1 Building addition Irequired.] 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 nop insurance required.]t 12.9Roof repairs - q ] employees.[No workers' comp.insurance required.] 13.9 Other pplicant that checks box ill must also fill out the section below showing their workers'compensation policy information. • owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. rotors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. zn employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 'lotion. nceCompanyName: mite ‘r.1 I-(U r— #or Self-ins.Lic.#: visa! /fir Expiration Date: (—I — ?019 to Address: _ vial , C Ci ip: oa Co e la copy of the workers'compensation policy declaration tpage( o ing the policytnumber I and expiration date). . to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 3$250.00 a da a:ainst the violator. Be advised t•.t a copy of this statement may be forwarded to the Office of gations . the DIA for insura• - overage veilon. /i reby certify un # s penalties o Crjuzy that the information provided above is true and correct. : or- -a. Date: I a0i' is 1 - 77 , \ :Muse only. Da not write in this area,to be completed by city,or town official • or Town: • ng Authority(circle one): Permit/License# tard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ---......8. .I her act Person: C-1\---_, 1` ' Phone#: V^\� �D e