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Home My WebLink AboutG-19-2817 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK lEt- ®cit _4 CITY 9paw` r I MA DATE I o-31- 18 PERMIT#4A &/-a0ag/ JOBSITEADDRESS S\ G' eweeQ L-wc-eP"`e?& I OWNER'S NAME Ev:c l? row 11 eIT GOWNER ADDRESS Snom-e ITEL-fly-T22-on&& FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL❑ PRINT ,�/ CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:L:l PLANS SUBMITTED: YES NOD APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER " BOOSTER CONVERSION BURNER �_, Ii 1... I NE NC DIRECTRECT VENT HEATER RSIIIIM , ,, ' , , se FIREPLACE ��I�FRYOLATOR MI _i Mill,I=IIM:IMi MS i �1�� ne_��II�� GENERATOR la al ��aNCtU :� IM,�� ,MIS s Emon,ommi GRRLLECE 11.11111Malltiotwmtimila mil, I_-- il11 � INFRARED HEATER liii ; - , AMAKER,.. I 1 , I � I, POOL HEATER I ROOM ISPACE HEATER _ ROOF TOP UNIT o UNIT HEATER i l 1 1 UNVENTED ROOM HEATER WATER HEATER / 1 i i illitMall OTHER m fl l� 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER 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 I hereby certify that all of the details and Information I have submitted or entered regarding this application are true 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 compli e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,ra PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MPD MGF❑ JP El JGF❑ LPGI❑ CORPORATION❑+ # 3281C PARTNERSHIP❑#. LLC El COMPANY NAME: EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE I CITY SOUTH YARMOUTH I STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 I CELL N/A EMAIL accountspayable@efwinslow.com 1 .0.l.. • \ A ns. a.van..wsa rYt.asasn J aussuusss..sasus.asu r Department of Industrial Accidents 9,_ i) i= t Office of Investigations t = Y;i= 600 Washington Street • =I f Boston,MA 02111 \.`=� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� 1 1 Please Print Legibly Name(Business/Organization/Individual):t�� E•C•Wrn$1 o�,.! Y t3,..6 tent() g t4 con ee., I el( , Address: 7. Q eoc6i C aJo (ll City/State/Zip: So,s 'crv-o.,-in Mk Phone#: -11-7Ci Are you an employer?Check the appropriate box: Type of project(required): am a employer with 70 4. ❑ 1 am a general contractor and I 6. 0 New construction employees(full and/or part-time)* have hired the sub-contractors :.❑ I am a sole proprietor or partner- listed on the attached sheet.s 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers' comp.insurance 5. ❑ We area corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 1.0 I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.0 Other thy applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 'formation. /� isurance Company Name: �Yp.,J C-LitO.A 4.1.,npuckr1( Car„ytk✓ty olicy#or Self-ins.Lich�.^^#: 1$a I A Expiration Date: (-] - a Ol9 ib Site Address: 3 �MMcylvr?a-1411 1k ./ C 3k l'I1,l City/State/Zip: 0,)4 to? 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 )\‘' 1 li: 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 t a copy of this statement may be forwarded to the Office of instigations the DIA for insura overage verif a on. do hereby certify un ze ains an penalties o p jury that the information provided above is true and correct. ignatu Date: la) 3I i 2017 hone#: Sfi:314 • 777g 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): re 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: