HomeMy WebLinkAboutBLDG-19-001730 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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• m CITY /� , .. MA DATE e 1 PERMIT#b,U/Q_0° I
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JOBSITE ADDRESS'"AT- 5J2Zi 1-744 �_..I OWNERS NAME , //
W a r_y_tt . . i GLS
GOWNER ADDRESS - ,,,__ ITELye 7Z/. f iFAXµ_ .,,L
TYPE OR OCCUPANCY TYPE attn.COMMERCIAL—) EDUCATIONAL �? RESIDENTIAL! ?
PRINT "'
CLEARLY NEW:p? RENOVATION: REPLACEMENT: , i PLANS SUBMITTED: YES ( NOT',
APPLIANCES 1 FLOORS 8SM 1 2 3 4 5 6 7 8 9 13 11 12 13 14
BOILER _ .-
BOOSTER • ___ _
CONVERSION BURNER
COOK STOVE m� _
DIRECT VENT HEATER
DRYER
FIREPLACE 1
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS ,....
MAKEUP AIR UNIT
OVEN 3 .
POOL HEATER
ROOM ISPACE HEATER _
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
1 M..
WATERHEATER s�
.OTHER . .. .
— INSURANCE COVERAGE
i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [=NO _
, I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
4.
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ' BOND L.
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 '„I AGENT [3
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of tie 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 comp' nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /i i A- _
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PLUMBER-GASFITTER NAME STEPHEN A,WIN—SLOW— 1229 SIGNATURE
LICENSE# 29
MP! ;_ MGF L,_I JP.,, JGF, . LPG]. CORPORATION i+ # 3281E-• PARTNERSHIP_ # LLC' .`#_ _ i
COMPANY NAME: EF WINSLOW PLUMBING.,&HEATING ,!ADDRESS,8 REARDON CIRCLE
CITY SOUTH YARMOUTH i STATE MA - ZIP 02664 W TEL 508-3941778 —���µ„v”
FAX 508-394-8256 ,CELL N/A EMAIL accountspayable@efwinslow.com.-----..vMm
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SOC\ u... _~InalW..ry..w...• J a ra..ueu..u«uc.w .
Department of Industrial Accidents
1tr i
=,. Office of Investigations
T. '0yi_= 600 Washington Street
e. °i`1— ' Boston, MA 02111 •
k't•Nzi.'' www.mass.gov/dia '
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information C f t Please Print Legibly �r`
Name(Business/Organization/Individual): E•c.i, I031Co., CIL>.N�-,fe j L 1-�tcT•.nt; c ) I.'1( .
o
Address: S(' ker c$nn C:1(.0.42- o
City/State/Zip: Sc,:kt� 'rrv�c;,,4-t-, NIS Phone #: 'V3- ,99-111 \ ,
Are you an employer?Check the appropriate box: • Type of project(required): W
#41 am a employer with -70 ' 4. 0 I am a general contractor and 1 6. 0 New construction
employees(full and/or part-time).* have hired the sub-contractors Q�
'. tam a sole proprietor or partner- listed on the attached sheet.t 7. Remodeling YJ
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity.. workers'comp.insurance. 9. ❑ Buildine addition
[No workers'comp. insurance 5. 0 We are a corporation and its p�
required.] officers have exercised their 10.0 Electrical repairs or additions l\
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#1 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 andjob site
rformation. /�� - 11
isurance Company Name: PYtc..t t'kJk'cL1 '�^wickftCO_ C'co vly
olicy#or Self-ins. Lic.#: 1 5 a I A Expiration Date: f—[ - ;)f;19
Al Site Address:a3 , cv1%,tee_kb- ! � C'e \1'h:T int` City/State/Zip: O,4'-I107
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
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
1
lup to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
tvestigationsttSf the DIA for insura9ee,overage veri$ation.
i / /
do hereby certify un a repnan penalties o pe jug that the information provided above is true and correct
icnatu s A Date: (a) a i l act-/
7
hone#: cut 359 r 773 N
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 Q
6.Other
Cil ( s
Contact Person: Phone#: