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HomeMy WebLinkAboutG-19-2197 Z::---1n-g PERMIT# /�/�( —��n2` .c. CITY` YArn1-QO+bt I MA DATE1-7711751 ;e/g7 ` / / JJOBBSITT DDRESS1tISettside IIIIA9C YAlrn7VFLIOWNER'S NAME a is g Gd2} }ADDRESS I CGl'Y1 Q ITE 0' "% 0 I 1 FAX'S TYPE OR OCCUPANCY TYPE. COMMERCIALQ EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:O REPLACEMENT: 'L�' ,10-57 PLANS SUBMITTED: YESO NOD APPLIANCES I FLOORS-4 I SSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER 1111__ CONVERSION BURNER COOK STOVE - DIRECTVENTHEATER _- M_ l DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR - -- 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 0 NO 0 CD I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I] OTHER TYPE INDEMNITY 0 BOND ❑ • '• + OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the --F-- Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 O 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 a 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 compile all Pertinent provision of the :Massachusetts State Plumbing Code and Chapter 142 of the General Laws. "MSI _ j C PLUMBER-GASFITTER NAMEI STEPHEN A.WINSLOW I LICENSE# 122981 JSI NAT E Cr r MP 1:1 MGF❑ JP JGF❑ LPGI❑ CORPORATIONQ#I3281C (PARTNERSHIP©# ILLC❑#I • I CP COMPANY NAME EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE CITY (SOUTH YARMOUTH I STATE MA ZIPI 02664 ITEL 508-394-7778 et FAXI 508-394-8256 I CELL N/A EMAIL(accountspayablet(a,efwinslow.com • (.,1?9- tis, J Maa in. LVII6aI.VISIYi4IIII0 y lI1M0J1.04I01.SJ{.I40 1 == Department oflntlustria!Accidents C.__,1=�1 ='k_ Office of Investigations ;MIEfi-`_2 600 Washington Street '� i,_,. Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers licant Information Please Print Le•'bl arae(Business/Organization/Individual); I .t .W taw �U t ddress: ; ; -tour! 't t. ity/State/Zip: as in lin h1a Phone#: 503-39Y-1`17Sf you an employer?Check the appropriate box: ram a employer with 70 4. 0 I am a general contractor and I Type of project(required): ] employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction I am a sole proprietor or partner- listed on the attached sheet.3 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ working for me in any capacity. workers'comp.insurance. Building [No workers'comp.insurance 5. 0 We are a corporation and its 1 ❑Build ng addition Irequired.] officers have exercised their 0.0 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 §1(4) insurance re uired. t y I and we have no 12.0 Roof repairs q ] employees.[No workers' • comp.insurance required.] 13.9 Other ppliwnt that cheeks bok#1 must also fill out the section below showing their workers'compensation policy information. • :owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tctors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. m employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site nation. nce Company Name: g un vs C•ku tveA r" #or Self-ins.Tic.#: Sal tt Expiration Date: 1-1 — aO9 teAddress: awea(}h (,� t- f 1 t1,. I r a copy of the workers'compensation policy declaration page Mowingtithe ppolicy number l and expiration date). :to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a 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 o$250.00 a da a::inst the violator. Be advised t•.t a copy of this statement maybe forwarded to the Office of gations I the DIA for insura, - overage veru on. i reby certify un • penalties o I• u �j ry that the Information provided above is true and correct. N R.. Date: 1 . t ail' t: 1 . 797: aa[use only. Do not write in this area,to be completed by city or town official • MU or Town: I ` ng Authority(circle one): Permit/License# tard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector her \ act Person: Phone#: • v �\