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HomeMy WebLinkAboutBLDG-19-002972 te a� CITY I `Arm oul4n I MA DATEI 1 1 /q J / 8 I PERMIT# / 1r_iq-cv°c'` 2 JOBSITEADDRESSIII, BOW 0 Od iron/ *In OUsA&(4OWNER'S NAME I Mw1 G iHHen Got/J�� til/ 1 02. Al ADDRESSI 5am11 ITEIISO$1"1412'45 IFAXI I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATI L 1 RESIDENTIAL®` PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO0 APPLIANCES' FLOORS-' 95M 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER , _ ®��llin 2'. CONVERSION BURNER NM .MS 1S NM NEM MI NM S_S -- ' DTT E _..111.11.1.1111=mnra " DIRECT VENT HEATER DRYER - -w _ FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE .- - ,..- r - 'am.' -..- rrim _ _-es"'_- r' -. ^ • INFRARED HEATER, LABORATORY COCKS c_ _ MAKEUP AIR UNIT 1 r.� OVEN .. -- - s4 ., r POOL HEATER . _ ROOM I SPACE HEATER t e 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 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0 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 0 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 an ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in complian ith all Pertinent provision of the .. :Massachusetts State Plumbing Code end Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A,WINSLOW LICENSE t SIGNM E 12298 MPO MGF© JP ID JGF❑ LPG'❑ CORPORATIONQ# 3281C PARTNERSHIP❑#) ILLI❑#I ' I 1 COMPANY NAME'EF WINSLOW PLUMBING&HEATING I ADDRESS'8 REARDON CIRCLE I L-) CITY I SOUTH YARMOUTH I STATE MA ZIP'.02684 ITELI508-394-7778 I —.re, FAX'508-394-8256 I CELL,NIA IEMAIL accountspayable@efwinslow.com I Cf' rl. O S\ AL S&L yVII6IIiVI•II441.6I0 V 3I100.)JMLfl eut.suJ 11- = l Department of Industrial s,1 Rp7r5 Office of Investigations :SINE S� 600 Washington Street �."�a,Ag Boston,MA 02111 www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers .pplicant Information c f Please Print Legibly lame(Business/Organization/Individual): a•F.wt,si0 elo�1; g 'j �• n (', j `'{0. �+Q. \@}int. .ddress: S �eodan C ae— (J UI ity/State/Zip:_ cks• ,W, t4 Phone#: IN-399-17?Q e you an employer?Check the appropriate box: ed): Kir am a employer with 70 4. 0 I am a general contractor and I Type of New project r i employees(full and/or part-time).* have hired the sub-contractors 6. 0 constructions J 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. ❑Demolition working for me in any capacity. workers'comp.insurance. [No workers'comp.insurance 5. 0 We are a corporation and its 9. ❑Build ng addition required.] officers have exercised their 10.0 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),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.0 Other applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. teowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. -actors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site madam anceCompany Name: ht ,gs...) My e—A rt" y#or Self-ins.Lie. : 'i S i A — / Expiration Date: i �— a01 ite Address: oMn itee_L iy r.t C j�. � City/State/Zip: 0,4467 :h a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). •e to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a p 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 to$250.00 a da a ainst the violator. Be advised t..t a copy of this statement maybe forwarded to the Office of :igations theDlA for nsuraf overage vers a on ----7 ereby(( certify un a airs a penalties o p•jury that the information provided above is true and correct. uTes Date: la 1 3101 #: .SUg:35`t- 7978 'Ictal use only. Do not write in this area;to be completed by city or town official \ • y or Town: Permit/License# • ring Authority(circle one): board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector , I- )cher rtactPerson: Phone#: