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Home My WebLink AboutBLDG-19-001586 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t. m JOBSITE ADDRESS Lad p C.g __�OWNERS NAME : f(1 r c . k.= $ CITY ``[ 1 �(� MA DATE517�6 J($_ PERMIT# b M001 5-1‘ G , OWNER 14arj aril fTEL slid iFAXu _ TYPE OR -OCCUPANCY TYPE COMMERCIAL-1 EDUCATIONAL 7i RESIDENTIALI, PRINT CLEARLY • NEW::,. RENOVATION: �= REPLACEMENT: PLANS SUBMITTED: YES!'t NO(+_i APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 13 11 12 13 14 1_ BOILER M1 BOOSTER 1 CONVERSION BURNER v0 COOK STOVE -. •••• DIRECT VENT HEATER -----rt,,, DRYER FIREPLACE FRYOLATOR H r FURNACE f GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER J'_, ROOF TOP UNIT TEST _ T UNIT HEATER _ __ UNVENTED ROOM HEATER r 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 s NO Lj O I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW I LIABILITY INSURANCE POLICY is OTHER TYPE INDEMNITY „ `; BOND L. 1 I OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the tc,i Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER `„! AGENT ;, SIGNATURE OF OWNER OR AGENT I hereby certify that all of tie details and information I have submitted or entered regarding this application are t , 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 co .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# 12298 ' SIG ATUR c.iow. MPL,,. MGFL.I JP;,, JGF,, LPGI ' CORPORATION! # 3281C +NI PARTNERSHIP LLC. #: _y =#'_ .! COMPANY NAME: EF WINSLOW PLUMBING&HEATING r ADDRESS 8 REARDON CIRCLE CITY 'SOUTHYARMOUTH 1 STATE MA.. ZIP 02664 TEL 5083941778 FAX 508-394-8256;CELL N/A a _i EMAIL accountsp ableeefwinslow.com pr .._ 6 ICS X2D.C2‘ ..... ........................ ew Department of Industrial Accidents 0._ ' 1 / Office of Investigations _:,,�a_ •.:, 600 Washington Street it Boston,MA 02111 �'„t- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Legibly Name(Business/Organization/Individual): s•c•,w,,,,SkO_v Cr 1ke,..6;nc L l�{0b��1 J Cc Iel( . Address: `)� tkeorlun C51OA_ City/State/Zip: Scco-tr1 'cn�o„Nn Nr- Phone#: '5O 399-1"17S1 Arerreyouyan employer?Check the appropriate box: • Type of project(required): •,I� t am a employer with 70 4. 0 I am a general contractor and I 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.i 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity.. workers'comp.insurance. 9• ❑ Building addition [No workers'comp. insurance 5. 0 We area corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 1.❑ 1 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 repairs insurance required.]t . employees.[No workers' 13.0 Other comp.insurance required.] thy applicant that checks box#1 must also fill out the section below showing their workers'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 check this box must attached an additional sheet showing the name of the sub-contractors and their workers'com*policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. /� tsurance Company Name: fTy-{(O„ :A ihjc.1 't gyp`rnnCQ__ Cct vny olicy#or Self-ins.Lic.#: 13 a 1 A Expiration Date: (-1 — a019 It Ib Site Address:a3 Canninccnv..eJII% Ad-e C4� f6,4- 1711 City/State/Zip: 0)gto7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL 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 Fup to$250.00 a da a ainst the violator. Be advised tb t a copy of this statement may be forwarded to the Office of tvestigations the DIA for insurapeecoverage veri�aCton. do hereby certify un r s an /penalties o)pe juryllthat the information provided above is true and correct. iQnatu1 Date; l 3! 7 i ' o, hone#: c1) 394 - 7?73 . • Official use only. Do not write in this area,to be completed by city, or town official City or Town: Permit/License# Issuing Authority(circle one): \ ‘ ,.1 I. I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other � Contact Person: Phone#: "'VVV 1