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HomeMy WebLinkAboutBLDG-19-002127 • B Fy CITY( koVYf)UA I MA DATE) io/'i,/ r( IPERMIT#- I'1 1077 JOBSITEADDRESSI/5clab / /full tn4✓>`teIf *04-IOWNER'S NAME ! n i_011 . G OWNER ADDRESS I SAN& I TEII 2fl 7/*IFAX0 TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL 0 RESIDENTIAL PRINT PLANS SUBMITTED: YES❑ N00CLEARLY NEW:0 RENOVATION:0 REPLACEMENT APPLIANCES? FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 5_5IIIII5 555555 5® BOOSTER M_MNM,_I� SUSlMPMR,a® CONVERSION ��M®MkISMkMIMN _ sass_a COOK STOVE in a NM NM Will liniellIMI MI Mk 111.11.1111111 WWI DIRECT VENT HEATER MI Mlle MN Ille MI SS M'R MI 5 5 5 5 DRYER �MSMI�55Ss5MRMNMN 5 5 55 5 FIREPLACE i in _ FRYOLATOR , ' isnn motFURNACE WA 5��!s a lin m S PPM GRILLEATOR E M 111.111....el le S ien ME_m,w_s on INFRARED HEATER, ARS nu sam otos s555® LABORATORY COCKS M_ S®®__ 5F5 M NMMNNMI MN �h MAKEUP AIR UNIT S S:� 5111181 5IS55���� OVEN NOB Itl�1Svs_SS�sS 55 POOL HEATER NM®Nal_NS Mil S55:,ssM®MNale ROOM I SPACE HEATER S,I�S NM5MI55555 ell 111111 ROOF TOP UNIT as555 MINI5 5S 5 -5 ISIIIIR aaaaaa ■ sa%..9 UNVENTED ROOM HEATER NMI MI el ss s l% UNIT HEATER WATER EATER itnNM Mat NM Mtn al � t MINI IN_M MI 1•1111101.11 OTHER — Rn:m®mat � M o 5 Se I■■01.111.111 5 5 si atilt INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW k :NO LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:lam 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, Cho 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 my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in corn' • ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - PLUMBER-GASFITTERNAMEI STEPHEN A.WINSLOW LICENSE ' 12298 ' SIG ATURE MPD MGF❑ JP JGF❑ LPGIQ CORPORATION Ott,3281C 1PARTNERSHIPD#I ILLC[ICU COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY I SOUTH YARMOUTH I STATE MA ZIPI 02664 ITEL 508-394-7778 FAX)508-394-8256 I CELLI NIA jEMAILI accountspayable(aefwinslow.com /..—,` II Iwo L1 • 0216` 1'64 yVIIM ilfe&I•{.400,0 J 21.01411•116•11,10641•31.144 • l i w— t Department of Industrial Accidents =.t']il- Office o g te=l"clot_ " ff .f Investi ations _ 1�=9 • 600 Washington Street ' r Boston,MA 02111 Www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers licant Information cC f�^^ � �� Please Print Le'ibl arae(Business/Organization/Individual): !-•t'.winsiow tus 1 b• � g aFI� • a. nt. ddress: ; ;•Oaten :'t Q_ t ity/State/Zip: es‘s ycr> y tin Phone#: ') -399.1779 you an employer?Check the appropriate box: I am a employer with 70 q 0 Type of project(required): I am a general contractor and I iemployees(full and/or part-time).* have hired the sub-contractors 6' ❑New construction 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 working for me in any capacity, workers'comp.insurance. 8. 0 Demolition Building [No workers'comp.insurance 5. 0 We are a corporation and its 1 ❑ addition required.] officers have exercised their 10.0 Electrical repairs or additions II am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152, e ` insurance required.]t §1(4),e . and o khave no 12. Roof repairs q ) employees.[No workers' comp.insurance required.] 13.0 Other pplicant that checks boz NI 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 'ration. nce Company Name: jtf to vi tiO illeA (_a (NCtA • Ju:son #or Self-ins.Lic.#: j$a[ Pr !'� Expiration Date: Ba�ip to Address: 04Ne l Vifa-1 /�tr2 C I ll — / Cfty/ i a copy of the workers'compensation policy declarationpage(showing the policy number l and ex piration 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 fuse \�o$250.00 a da a:ainst the violator. Be advised t I.t a copy of this statement may be forwarded to the Office of gations I the DIA for insure, - overage veru on. i reby certify un - penalties oIfir u g that the information provided above is true and correct. T . . �' Date: ( . I am 3: 1 • 797; aal use only. Do not write in this area,to be completed by city,or town official • or Town: Permit/License# � ng Authority(circle one): mrd of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector .....NN her act Person: Phone#: • e