HomeMy WebLinkAboutBLDG-19-001806 . _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITEADDRESS114,1,0 wet oK Rc-1 � OWNER'S NAMEG76 rea LC%IA fad-:_:-_:.._'
OWNERADDP.ESS ( �� ...,.„______-_--;TEL 9 :27 1FAX: _
TYPE OROCCUPAN'CYTYPE COMMERCIAL-- EDUCATIONAL' I RESIDENTIAL
PRINT ✓�
CLEARLY —NEW:j7 RENOVATION:: REPLACEMENT: I PLANS SUBMITTED: YES' J NO!/:
CVAPPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 15-1 11 12 13 14
/t BOILER -
V. ., BOOSTER • _ .. _ _ __ —
do CONVERSION BURNER
•- COOK STOVE r
DIRECT VENT HEATER
• DRYER
O FIREPLACE
FRYOLATOR
2 FURNACE .
GENERATOR —
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT _
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER ... . .. .. .
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L”NO 4_1
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
' LIABILITY INSURANCE POLICY Lii OTHER TYPE INDEMNITY 1111 BOND L
LOOWNER'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.
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W CHECK ONE ONLY: OWNER ',,,•J AGENT 11:1SIGNATURE.OF OWNER OR AGENT
I ' 1 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
�"�l and that all plumbing work and installations performed under the permit issued for this application will be in complia •e with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNAT E
MP 1± I
, MGF _I JP;, JGF LPG' CORPORATION
# 3281C wIPARTNERSHIP_..,#. tLC #
COMPANY NAME: EF WINSLOW PLUMBING&HEATING i ADDRESS 8 REARDON CIRCLE
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CITY SOUTH YARMOUTH _ _,; STATE MA 'ZIP 02664 TEL 5083941778
FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com - — _
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Department of Industrial Accidents •
l:_'>inht Office of Investigations
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r WO 600 Washington Street
-'1=1= a Boston,MA 02111
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@= � www.mass.gov/dia •
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 3/4..-
Applicant Information f y l Please Print Legibly
Name(Business/Organization/Individual): E.C.1.4,,n5IGs, Qtti,._�ii.•tc f t-Ita1,,,,., Ct) in( •
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Address: " kec can Carr.I.Z
City/State/Zip: Sc,$.in '4n'-,o.,l-tn NJ} Phone#: 1T3S- 399-117 SI
Are you an employer?Check the appropriate box: Type of project(required): ----.--->-.........._
1.
,, I am a employer with 70 " 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
'.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
working for me in any capacity.. workers'comp.insurance. 9. 0 Building addition
[No workers'comp.insurance 5. 0 We area corporation and its
required.] officers have exercised then 10.0 Electrical repairs or additions
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]1- employees. [No workers' 13.0 Other
comp. insurance required.]
thy applicant that checks box HI 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 fob site
formation. Ant
isurance Company Name: b t..y ;A 1-u0-4 '.�a Lys el C Go a,il
olicy#or Self-ins.Lie.#: 15 a l / ' Expiration Date: (—[ — ,aOi9
)b Site Address:,3 LC t rvvkvl4tee_t}4"1 -Ad-eCp,e3 . IAA t City/State/Zip: 0,)L-141?
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 MOL 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
Fup to$250.00 a da against the violator. Be advised that a copy of this statement may be forwarded to the Office of
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rvestigations the DIA for insura overage veriftation. .
do hereby cerlify un a re pains an penalties o pe jury that the information provided above is true and correct. (\\
ignatu Date: [a! 31 19.0;7 \
hone#: Stq S'1 . 7 J 78
Official use only. Do not write in this area,to be completed by ciy or town official
City or Town: Permit/License#
Issuing Authority(circle one): s"---.........`
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
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6.Other
Contact Person: Phone#: k\ O