HomeMy WebLinkAboutBLDG-17-004959 J g . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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SW/ Q.3/4 •J PERMIT# &-- 3-
-1�F' CITY 1 �, �1 r � . a �� MA DATE, O ..(-7_
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JOBSITEADDRESS SO-.,i)b1` e,-,RQ, , OWNERS NAME �-(� j• �3 �� -•
G --o - - ,. ._ -71 TELT -. . • FAX' __ ...
OWNER ADDRESS �.�'��e[5.arr�N�Atx��a��,4 03 . r
TYPEOR OCCUPANCY TYPE COMMERCIALEDUCATIONALTi RESIDENTIAL.2Y
CLEARLY NEW:_i RENOVATION:El; REPLACEMENT: __L/ PLANS SUBMITTED: YES NO4'
APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER .. . ......--
COOK STOVE 1 • _ _
_ - __ c I_..! ._ ,, .__-_J . .... ,_.I
DIRECT VENT HEATER -__! .,-J -r l ._• _._,_,.' —.I_..,_-- ,.-.., .._..._[ .__ -
DRYER i,
FIREPLACE
FRYOLATOR _-
_ _
FURNACE
GENERATOR
.
GRILLE
INFRARED HEATER ,--.,.--._10 -
LABORATORY COCKS -
MAKEUP AIR UNIT
OVEN
POOL HEATER • - .__,:
ROOM I SPACE HEATER ! ! -- --- -
ROOF TOP UNIT ._ --- ---- - •-. : •.,-__ _ . - ! -
TEST T __ J�I _ I
UNIT HEATER ��i . . . .
UNVENTED ROOM HEATER _ - --I - .__
WATER HEATER.._-------- --.-- _ -, —!A - r- _! _ _.i � I '' _
OTHER. - — i --
------ -_T M..,. ...-_ . INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 14!NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY '7, OTHER TYPE INDEMNITY -,.J BOND Li
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 ._J AGENT L_1
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 and accurate to the best of my knowledge
end that all plumbing work and Installations performed under the permit issued for this application will be in compllan - ith ell Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws, r / /
PLUMBER GASFITTER NAME STEPHEN A.WINSLOW •_ 1LICENSE# 12298 ' r SIGN' URE
MP .1 MGF JP : JGF LPG' CORPORATION ++I# 3281C__•_'. PARTNERSHIP__# -� LLC,,,i#. -••r.
COMPANY NAME: EF WINSLOW PLUMBING&HEATING 'ADDRESS 8 REARDON CIRCLE _-_ ,
CITY SOUTH YARMOUTH i STATE'-MA tZIP 02664 TEL 508-394-7778 _�- •
FAX'.508-394-8256 !CELL N/A I EMAIL accountspayable@efwinslow.com w,,
P ( 7 - 1c? iv • 0,a , 5qf a
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The Commonwealth of Massachweits
f ft Department of Industrial Accidents
riff= 1 1 Congress Street,Suite 100
r:_
_.e�E Boston,MA 02114-2017
;� www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly 0.
Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH,MA 02664. Phone#:508-394-7778
Are you an employer?Check the appropriate box: Business Type(required):
1.❑✓ I am a employer with 7® employees(full and/ 5. 0 Retail
or part-time).* 6. ❑Restaurant/Bar/EatingEstablishment
2.0 I am a sole proprietor or partnership and have no
7• El Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
• [No workers'comp.insurance required] 8. 0 Non-profit
3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees.[No workers'comp.insurance required]**
11.0 Health Care
4.Ell We are a non-profit organization,staffed by volunteers, •
with no employees.[No workers'comp.insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#l.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:23 COMMONWEALTH AVE
City/State/Zip: CHESTNUT HILL,MA 02467
Policy#or Self-ins.Lic.#1821A01/01/201/Expiration Date:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
fine 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
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification..
I do hereby cerci the ayhs and enalties o perjury that the information providedlabove Is true and correct.
Signature: /$L-" ..osse h.e. Date: ia. 1st /Ifo/
phone#:508-394-7778
Official use only. Do not write in this area,to be completed by city or town official
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City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia •