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HomeMy WebLinkAboutBLDG-19-002374 =-=-?w-1:T=""'—eE CITY 1001‘09.14n l MA DATEI t O 1 !S I 1 Q I PERMIT#- Dth. 19C t29 JOBSITEADDRESSII'ki PInc AA4CF. c 1h.,Y4f4 m1 OWNER'S NAME IJ0.c / Canada G OWNkRADDRESS ) 5A,ne ITE1150€39g5'51t IMAMS TYPE OR OCCUPANCY TYPE COMMERCIALD EDUCATIO LD RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:D REPLACEMENT:0 PLANS SUBMITTED: YES© NOD APPLIANCES 7 FLOORS- BSM 1 2 1 3 4 5 ' 6 7 8 9 10 11 12 13 114 BOILER - — --- _ - BOOSTER COOKRIONBURNER �NSsa�OSS DIRECT VENT HEATER DRYER o I Neil= FIREPLACE FRYOLATOR ,_ -- .> I . FURNACE �,I � - � . - - +-- GENERATOR GRILLE - - INFRAREDHEATER, LABORATORY COCKS - b MAKEUP AIR UNIT OVEN , o .. ..., r -.i, POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER_1, FaTER - _ - OTHER __ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO D IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D+ OTHER PIPE 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. -J1 CHECK ONE ONLY: OWNER 0 AGENT 0 v SIGNATURE OF OWNER OR AGENT Prl a „ I hereby certify that all of the details and Information I have submitted or entered regarding this application are true a accurate to the best of my knowledge and that all plumbing work end Installations performed under the permit Issued for this application will be In complia - with all Pertinent provision of the M , ;Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - , :D PLUMBER-GASFITTER NAME)STEPHEN A.WINSLOW I LICENSE# 12298 '1. SIGNATURE S? MP ID MGFD JPD JGFD LPGID CORPORATIOND+ #I3281C I PARTNERSHIPD#I ILLCD#) etc COMPANY NAME)EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE I CITY [SOUTH YARMOUTH I STATE MA ZIPI 02664 [TEL I 508-394-7778 I ) FAX 508-394-8256 I CELL NIA EMAIL)accountspayable(a,efwinslow.com 3 C"/20- =la 1164 11-,V//6I/w6 rvc.5 66,6 Vf /I1*WVN4/6. 10.0 rrit _=_= Department of Industrial Accidents. . _iel�el=Tr- 0 Office of Investigations ' _ (( 600 Washington Street -kr,,.0Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers licant Information Esc. Please Print Le'ibl arae Business/Organization/Individuat); E.f^.Wtjt,Slo 1 oU� 1 . {! 2.. at" . Q. 116 ddress: ; i; •trity • l .1 12.. / t • ity/State/Zip: al Ain ,,,,, in M Phone#: IA-394-1174 6 you an employer?Check the appropriate box: am a employer with '70 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* .. have hired the sub-contractors 6 New construction 7. 0Remodeling ] I am a sole proprietor or partner- listed on the attached sheet ship and have no employees . These sub-contractors have working for me in any capacity, workers'comp,insurance. 8. 0 Demolition ` .. [No workers'comp.insurance 5. 0 We are a corporation and its 1 ❑Building addition 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 repairsinsurance required.]t employees.[No workers' comp•insurance required.] 13.0 Other pplicant that checks bok NI must also fill out the section below showing their workers'compensation policy information. :owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tctors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. zit employer that is providing workers'compensation insurance for my employees. Below is the policy and job site nation. .3t> nee Company Name: huit,‘..../ HU �� 1_(_• • A • °sea rn #or Self-ins.Lic.#: $a /1t �` Expiration Date: (—) — aO1G1 , ii !e Address: Lievoanw•pa_1}� ,(•in r t t all rnll City/State/Zip: Oayto7 1 a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a (\ 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 U' a$250.00 a da a:ainst the violator. Be advised t a.t a copy of this statement may be forwarded to the Office of gallons r the DIA for insure, - overage veli;on, - reby certify un • penalties o 'jury Haat the information provided above is true and correct. i _ 1 • 797, I . _ Date: 1 . 1 2101. ... i - : - :dal use only. Do not write in this area,to be completed by city,or town official. , • or Town: ng Authority(circle one): Permit/License# lard of Health 2.Building Department 3 City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector her act Person• Phone#: a