The URL can be used to link to this page

Home My WebLink AboutBLDG-19-002782 n --;_ fFei CITY %INTO41 I MA DATEIUSIO l PERMIT# /l4D/r/9-a0.Z/6.2 JOBSITEADDRESS'if AvsetLn Wes* Yalnaulboa67jOWNERS NAME I Tlta,45 NfcTo I GOWNER ADDRESS 5t,wit ITEII q/7fl1-946a 'FAX' I . TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL RESIDENTIAL PRINT �,/ CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Ef PLANS SUBMITTED: YES❑ N00 APPLIANCES 7 FLOORS-+ J BSM 1 2 3 1 4 5 " 6 7 8 1 9 1 10 11 12 13 14 BOILER .. ____ __ . _- _ - - _ _ .._ . — BOOSTER - - CONVERSION BURNER _ . — COOK STOVE _ -- DIRECT VENT HEATER — - ` DRYER FIREPLACE - --. FRYOLATOR FURNACE GENERATOR - . - GRILLE _ INFRARED HEATER, LABORATORY COCKS - . MAKEUP AIR UNIT OVEN ,■, POOL HEATER ROOMISPACEHEATER .t - ROOF TOP UNIT TEST UNIT HEATER - - UNVENTED ROOM HEATER WATER-EATER 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❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY CI OTHER TYPE INDEMNITY❑ BOND El 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 1/4..1 I hereby certify that all of the details and Information I have submitted or entered regarding this application are true d 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 compll a with all Pertinent provision of the N. •Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �.%Liw co PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE12298 SIGNATURE v MP 1:1 MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION 0#113281C I PARTNERSHIP❑#) I LLC 0#1 M I — �- COMPANY NAME'EF WINSLOW PLUMBING&HEATING ADDRESSI 8 REARDON CIRCLE 1/4-11 r CITY I SOUTH YARMOUTH I STATE MA ZIP102664 ITELI508-394.7778 I W FAX 508-394-8256 CELL N/A IEMAIL accountspayable@efwinslow.com I d V• 41 J In Sika a•ss. t,v,ea•w,srr s.•sss•s tt y,aw.russs.,esv.res•u =- Department of Industrial Accidents • I •= ,1= Office of Investigations . i f_ 600 Washington Street •,�Y Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers kimlicant Information Please Print Legibly iame(Business/Orgenization/Individuaf); E•C .Wtys�pW most Ow I t1 1 . .ddress: $' &eocloh Cadyo ity/State/Zip:_ o,t{v _ � y, h�c Phone#: 5[)E-399-177Si e you an employer?Check the appropriate box: am a employer with 70 4. ❑ I am a general contractor and I Type of ewprco t s(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑Nconstruct on 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. El Demolition working for me in any capacity. workers'comp.insurance. [No workers'comp.insurance 5. 0 We are a corporation and its 9. ❑Build ng addition required.] 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,§I(4),and we have no insurance required.]t employees.[No workers' 12.❑OtheRoorepairs comp.insurance required.] 13.❑Other applicant that checks boil#1 must also fill out the section below showing their workers'compensation policy information. ieowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'actors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.- an nformation.an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site mation. ante Company Name: gV is tiotveA i y#or Self-ins.Lic.#: {Z a.i /fir Q ('� Expiration Date: {—t — aDi / ite Address: �onwwcwea.tlhJ. C_ 1, � } ��{ City/State/Zip: Dag ft,? :h a copy of the workers'compensation policy declaration page('showing the policy number and expiration date). '•e to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a p 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 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 Ligations • the DIAfor insur:• - overage verij on. \` ereby certify an fns a penalties o jury that the Information provided above is true and correct. • . ` Date: tai 311a011- \ • #: St)t3I'j- 7978 7clal use only. Do not write in this area,to be completed by city,or town official • y or Town: Permit/License# ling Authority(circle one): board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector --",..:::::.\-* )ther \\ matt Person: \. Phone#: