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Home My WebLink AboutG-19-2956 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 't' I CITY ye Atm.,'>Y/f MA DATE ///y/c- PERMIT# /3,06-4;901o19156 JOBSITE ADDRESS /I S£ns/sir/1/...44 6,-, OWNER'S NAME nLB£.er nieex. G soo77 y�no.ry OWNER ADDRESS Spm- I TEL 5 5g—f$'AOya7 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL' PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES❑ NO0 APPLIANCES 7 FLOORS-0 BSM 1 2 3 4 5 1 6 7 8 9 10 I 11 12 13 14 I BOOSTER N 1 CONVERSION BURNER I `I I i .i I COOK STOVE DIRECT VENT HEATER i I 1, t DRYER 1 I _ _ FIREPLACE FRYOLATOR 1 sii 4 -- - - II I GENERATOR I f _ GRILLE _ 1 I INFRARED HEATER I 1. _ 1_ LABORATORY COCKS I MAKEUP AIR UNIT r r -, l -Ir OVEN I 7 -1 r POOL HEATER ROOM/SPACE HEATER — Hr _ _ ROOF TOP UNIT r - TEST l UNIT HEATER r ,v_ i - ,i UNVENTED ROOM HEATER l,j WATER HEATER OTHER h'II _ I ET. , INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES El 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 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the I Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT 0 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 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 compli e with all Pertinent provisionpof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. sts-G�"r�.vra/ PLUMBER-GASFITTER NAME I STEPHEN A.WINSLOW 1 LICENSE# 12298 - SIGNATURE MP MGFQ JP❑ JGF❑ LPG!EI CORPORATIONQ# 3281C PARTNERSHIP❑# LLC 0# COMPANY NAME: EF WINSLOW PLUMBING&HEATING !ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com 42/L 56 c'3 • =) \ if. � I ,,I 1 Oa f r,, ..If n ,J s ssaaJMFInn., .,, l5.. Department of Industrial Accidents 10=, ]itU= t Office of Investigations e _ 600 Washington Street ='iT=` 4� Boston,MA 02111 %,,T, 617 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name(Business/Orgganization/Individual): E,C.wig,5m0„„ Q[U✓-vb�nc� a. t.1ottr.,.vp Ce,, Inc. Address: 7' (4ocltan C;�� OX City/State/Zip: Sou Ain 'crwK3.A-tn t4Ar Phone#: '5D5- 399-1'17C/ Are you an employer?Check the appropriate box: Type of project(required): Al am a employer with 70 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors :.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. ❑ Building addition [No workers' comp.insurance 5. 0 We area corporation and its required.] officers have exercised their 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.]t employees.[No workers' comp.insurance required.] 13.0 Other 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 and job site formation. ,,,1//�� - II tsurance Company Name: P TY tm.,.i t ihie.A l i ftirtt n t,ra_ Cq,,Netvty olicy#orSelf-ins.Lich.^# ed : 1aI Pc '1 Expiration Date: (—] — ani9 )b SiteAddress:D3 Gnnt*Aw,v.•eo.J#h A1/41"4/ C4e3 1'n�U City/State/Zip: Dag lo7 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 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 ` � rvestigations the DIA•for insura overage verif a on. a f do hereby certify un re ains an penalties o p jury that the information provided above is true and correct. ipnatu : A Date: b.) 31 d aot7- k hone#: c,)g:3119 . 727g Official use only. Do not write in this area,to be completed by city,or town offlciaL • • City or Town: Permit/License# Issuing Authority(circle one): N. ��JJJVVV I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector .:‘,>. (1 6.Other \li Contact Person: Phone#: \�