HomeMy WebLinkAboutBLDG-17-004937 Sa _
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'm CITY L u 04' r I rer MA DATE 3- -2-7 7/71 PERMIT#fDb00W 7
JOBSITE ADDRESS 2D hJg,rek c,C. pa ce I OWNER'S NAME .P1 c/C Cit ce'L fit/ • j
GOWNERADDRESS o ,'c , • Ln' £fi7/, )TEL: T/767SOS3_FAX ITYPPRINT OCCUPANCY TYPE COMMERCIAL J EDUCATIONAL J 7`Sy12E,,33 SIDENTIAL�
CLEARLY NEW:',,J RENOVATION: REPLACEMENT: A PLANS SUBMITTED: YES NO _J
APPLIANCES 7 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1 _1 -.-_ I _I 1 1 1_1 I _J
BOOSTER i___ 1 __..__-) _.___.I _ I _1, _._l 1 ..,_... ! _. _J _.__J _ I I.____I
CONVERSION BURNER I ! 1 ....1 1 . ..I 1 ....1 _.._I 1 ..._! _f_.__1 n ...,..1
COOK STOVE _.___._I __ I 1 I__I __I _ _'.
DIRECT VENT HEATER 1 _1 _1 _I ...-1 !' 1 1.-__- _ ! _J _ J, ! __,_.1
DRYER J ._.,._„1 .....,J __I ___._.J _1 _1 I __J
FIREPLACE _1 __.__I ' ' t -.__ ____I I T1 1
FRYOLATOR __J—J __1 t I _. _I _l_
FURNACE ._.,...1 J ___.1 J ____1 I -!
GENERATOR _i 1_ ^1 I _ l 1 __1 I ____1
GRILLE __I —ill _J 1 _ 1'. 1 t _ 1
INFRARED HEATER .-_1 __.__I ..___. 1 _._..._1 . _.. --- _.�.i _ I ___. __ _
MAKEUP AIR UNIT
OVEN
POOL HEATER 1 _ _J I ^I _I_._I ____1
•• _1, _i 1 _1
ROOF TOP UNIT - _1_ 1 TEST -1 --1 _J 1 1
UNIT HEATER Hill
tHEATER1TER HEATERHER.. ., _ 1 J'__I 1 J .___J . 1 I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO 'J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY rJ 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 _! AGENT _J
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
and that all plumbing work and Installations performed under the permit Issued for this application will be In comp! .nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298SIG ATURE
MP !.J MGF .,.J JP .J JGF,J.LPG! _j CORPORATION +}#=3281C I PARTNERSHIP ,J#'.- - 1 LLC .J# I
COMPANY NAME E F WINSLOW PLUMBING 8 HEATING ADDRESS
8 REARDON CIRCLE
U M 4 TEL
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508 394 7778
FAX 5083948256 I CELL N/A EMAIL accountspayable efwinslow.com
Sare) ER41
=7"-r-- Department of IndustrialAccutents
''=?ltd`/ Office of Investigations
ion ' 600 Washington Street
=Fi= Boston,MA 02111 •
V
www•massgov/dna •
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Anuiicant Information C l { Please Print Legibly .•
Name(Business/Ortgianization/Individual): E•F•WwxSIovsJ Qv�bwtel L 0ta.V , Ve) Mt
Address: ' �Padwi Cart .2. Q o
City/State/Zip: Saki k'+ NA' Phone#: `5O1;•3R9-1`i 1St
Are you an employer?Check the appropriate box: Type of project(required):
,g1 am a employer with —70 4. 0 I am a general contractor and 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. 0 Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its
required.] 10.0 Electrical repairs or additions
officers have exercised their
I.❑ I am a homeowner doing all work right of exemption per MOL 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.]
thy applicant that checks box f 1 must also LII out the section below showing their worker'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 checkthus box must attached an additional sheet showing the name of the sub-cont actors and their workers'comp.policy Information.
!m an employer that is providing workers'compensation insurance formy employees Below is the policy and job site
?ormation. /� - � •
tsuranceCompany Name: t�iCYD..-1 t k't-uaA ic>tuftct ` ar''ytyli
•
olicy#or Self-ins.Lie.#: ] 3 a I Ac Expiration Date' c--1 — non
lb SiteAddresO3 Conrynnyi °J'T'n Guru'u' i\1 City/State/Zip: C.1r4 '7
.ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). •
allure to secure coverage as required under Section 25A of MOL 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 t the violator. Be advised t a copy of this statement may be forwarded to the Office of
•
tvestigations
Cams
insurape •average veri a on. r
do hereby ter*?u •^ ,e ains ant penalties o p Jury that the information provided above is true and correct.
jfmal lteL Date: ia 211 ROIL
hone#: Chit•2SM• '177X
Official use only. Do not write in this area,to be completed by city,or town official - '
City or Town: 1'ermlt/License I/
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
,