HomeMy WebLinkAboutG-18-2661 I
t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
,fig, -..... ........ ._ . ...... r.
\Ti _
`a��l=�' CITY � � w• M ■. A • MA DATE..ITZ�C�)..L... - PERMIT# ..... _.
CSC }� r OWNER'S NAME 3.Vsto,aI .z-_ 11
JOBSITE ADDRESS L�._.1_1� �T. -..._.
G OWNER ADDRESS WeZf p rE-L
7n� .FAX',...____..*:
..i
)
TYPE OR OCCUPANCY TYPE COMMERCIAL,„ EDUCATIONAL . RESIDENTIAL 1
PRINT / -
��'Y NEW:_i RENOVATION:rr. REPLACEMENT:../..-1------- PLANS SUBMITTED: YES NOL;j
APPLIANCES'1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER SISI - -NN �®� Q
BOOSTER • � P���®Sn flSMNISSININEENIN C
CONVERSION BURNER h ;I�EN�®®�
COOK STOVE I __.1 _ M�®� at®�
DIRECT VENT HEATER ®NNINNeePINWINIM
DRYERaginwapittE �
NFI
FIREPLACE . • -®���IN® IN CD
FRYOLATOR rellinimm. preausrtmumelMillila
FURNACE ! WAINISENNNN1MUNINE c-�
GENERATOR • iOI®IS,MINANNJ�_M �l�9
GRILLE MiliNINIPINICISP,r.�LrL/ � NEENINE
INFRARED HEATERm1------- MI
LABORATORY COCKS ��t� ®
NI �� ELE
MAKEPAUNITIINEMENIE�.,�ININININUS
OVEN .....- - .._......__.iNNPINN=SdNINIIIEPNISINNINNBMIN
Room ISPACE HEATER ---•.—._. �
ROOF TOP UNIT -—.-. ---j-:---';L� llM11111MINSI 1101110®
TEST — .._.1_IIINE���®® ®®I,_EWININ • .
-UNITHEATER.- • .... ... ----. .._..—.._..._.r—.1�=I ® M==--.— . .
UNVENTED ROOM HEATER ___ _:®NEWN��® ®NEM
INE
WATER ESTER..- - .........-- WinallinINIPSO®SEME�®®�ME
DIM. 2-I _ - ®®��® ®Mi
+-^T-^T.
MINNIENEINEMENEENINIENIESPIWINENSININE
INSURANCE-COVERAGE +
IhaveacurrentliabllityInsurancepolicy or Its'substantial equivalent which meets the requirements of MGL.Ch.142 YES I NO .. I
I IF YOU CHECKEDYES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY''_ OTHERTYPEINDEMNITY j BOND Li
OWNER'S INSURANCE WAIVER:lam 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.
ri
CHECK ONE ONLY: OWNER L1 AGENT —
SIGNATURE OF OWNER OR AGENT
I hereby cerdfy that ell of the details and Information I have submitted or entered regarding this application are true end: curate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance 7i ell Pertinent provvision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i✓.L.�
r- SIGNATURE
PLUMBERGASFITTERNAME STEPHEN A.WINSLOW _ _LICENSE# 12298 _ r
-> ------r
MPI;MGF_ JP ..r JGF:_n. LPGI CORPORATION ,f_t# 3281-6PARTNERSHIP...:#�_ LLC,,,'#,r.,,.__.:
COMPANY NAME: W
EF INSLOLUM
W PBING&HEATING ADDRESS.B REARDON CIRCLE —,---,---.----n,--,
•CITY SOUTH YARMOUTH 1 STATE'' MM ZIP 122.1„,,,,iTEL 50839_- 4-7776_,__......_...---.-'
FAX:508-394-6256 1 CELL NIA •_ JEMAIL accountspayabieoaefwinsiow.coom D
•
•
The Cornratonweadtii of Massachusetts
rt IDepartmentofIndustrialAccidents
1!I 1 C'ongressStreet,Suite 100
l=
® Boston,MA 02119-2017
•
WWw.rnessgov/Tia •
Workers'Compensation Insurance Affidavit:General Businesses.•
TO BE RILE])WITH THE PERIWITING AUTHORITY.
Applicant Information
Please Print I,e¢ibly
Business/OrganizationName:E.F.WINSLOW PLUMBING&HEATING CO.,INC
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH,MA 02684. phone#:508394-7778
Are you an employer?Check the�appropriate box: Business Type(required):
1.0✓ I am a employer with -� _employees(full and/ 5. 0 Retail
or part-time).*
2.0 I am a sole proprietor or partnership and have no 6. 0 Restaurant ar at ng Establishment
7. 0 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.
3.0 We are a corporation and its officers have exercised 9. 0 Entertainment
•
their right of exemption per 0.152,§1(4),and we have 10.0 Manufacturing •
no employees.[No workers'comp.insurance required]"
4.0 We are a non-profit organization,staffed by volunteers, 11.0 Health Care
with no employees.[No workers'co
mp.insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section beiogshawingthek.workgsCwmpensationpolicy_infoimation.
**If th6to'ryomfe otncers E eixempted themselves.but the corpoationhas other employees,a workers'compensation policy is required and such an
organiationshould checkbox#I.
lam an employerthat is provhlingworkers'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.#1821A ate:01/01/201
Attach a copy of the workers'compensation policy declaration page(showinExpiration
he pol cDnumber 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,es 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. •
Idohereby cerlii the ayrsand, mattes pedury that the information provided above Is true and correct
Si: afore: '--_— •'-..
,a.a..v c`tr� Date: I e. /31 //‘
Rhone#:508-394-7778
•
•
Official use only. Do not write In this area,to be completed by city or town official
City or Town:
Issuing Authority(circle one):
PermitiLicense#
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/Tia