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Home My WebLink AboutBLDG-19-000564 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK cern= ,---e,1 ask(-sed CITY VAN iVW MA DATEy wawa PERMIT#/3LA6J'/9 010S(,/ JOBSITEADDRESS IAhff([2Rn�OWNER'S NAME (f.1(jc? P(-C✓5 G OWNERADDRESSI' SI LAK (QI ' LVCll P- SiQ MW (; 1 ITEL (07:1 6'3 o85)'FAX AN T TYPE OR OC YPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:IY'/ PLANS SUBMITTED: YES❑ NOM APPLIANCES 7 FLOORS–r BSM 11 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I I I - BOOSTER 1 1_ '_ CONVERSION BURNER - DIRECT OVE _ DIRECTVENTHEATER _ l . .s DRYER FIREPLACE FRYOLATOR bg .] _ _ _ _ !_____ ti GENERATOR G - INFRARED HEATER � LABORATORY COCKS - MAKEUP AIR UNIT OVEN 1 POOL HEATER ROOMISPACEHEATER ROOF TOP UNIT r TEST UNIT HEATER UNVENTED ROOM HEATER W__ _ WATER HEATER _ _ — OTHER r - � � _ l i i, INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND CI 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. 0 CHECK ONE ONLY: OWNER AGENT El SIGNATURE OF OWNER OR AGENT --I, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge t^ and that all plumbing work and installations performed under the permit issued for this application will be In com nce with all Pertinent provision of the q .Massachusetts State Plumbing Code and Chapter 142 of the General Laws. laza sr V PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MPD MGF❑ JP JGF❑ LPGI❑ CORPORATION 0# 3281C PARTNERSHIP 0# ILLC❑# COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE � ( ' CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 _ FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com • M\ ane t...uun.rone.sasu pJ 2,S.a0a.aeua.ua.aau . - =AM.= Department of Industrial Accidents M''• 1,_,: _ l Office of Investigations _ i 600 Washington Street ' ='�1=`— Boston,MA 02111 aY www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Or/lganization/Individual): E.c.Wt„510�, Y1t..•,6w�t I_ 0,0.1-1 Ce•} 1n(, Address: '' &coni., C; jt. a OX City/State/Zip: So,) n var 'c,,,kn NP Phone#: 505-3R9-1'17 1 Are you an employer?Check the appropriate box: Type of project(required): Xam 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 t.❑ 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. 0 Demolition working for me in any capacity. workers'comp.insurance. 9• 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 1.❑ 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.] i 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 isurance Company Name: Am.. t% r 'k'tlo-A 1 7 s nit/t C2 \n arnotkini olicy#or Self-ins.Lich(.#: I S a I Pr '1 Expiration Date: (—I - aOl9 ib Site Address: 3 GAty mccn A 2o-1T n R./ C1'e3 i4 UI City/State/Zip: C,)'I le7 .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ------S.-%c 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$250.00 at da a ainst the violator. Be advised t u.t a copy of this statement may be forwarded to the Office of tvestigations the DIA dor insurageoverage veri a on. do hereby certify an.e re ains a 'l penalties o p•jury that the information provided above is true and correct. ignattih- Date: [d) 3I 1 WA' hone#: S()g:Mi 777$ ....\\ Official 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 `� 6. Other `v\ Contact Person: • Phone#: ^'�\ 4 I