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HomeMy WebLinkAboutBLDG-17-3909 • LCS, MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK • '11 •IFmkis c1+� _ .4 `z-VS( CITYigflt12Vo (05,5+ _ MA DATE WNW PERMIT if /11- 7-aa37,0 i JOBSITEADDRESS) SS 77/9-g774.1/ - IOWNERL /L�J 'SNAME) 4p 12,1*E.,-) C/�y OWNER ADDRESS . ._..___i, i_:. . ...la .---- TEW/Tc •b•O/ AXI 1 TYRE OR �� 1jLi(3alJo Fn HUNT TYPE COMMERCIALU EDUCATIONAL® . RESIDENTIALW CLEARLY NEW;D RENOVATION:0 REPLACEMENT:2/ PLANS SUBMITTED:YES® NO +3 APPLIANCES- FLOORS-) ow 1 ©OD_6 -e - 7 8 9 10 11 =CI 14 BOILER _a . ..1� _...__I :. 1...._.I`� 1�,�1_... 1 i .__ I BOOSTER I__„) _J._ -._-.;� �i(� I_.r•_t... l CONVERSION BURNER I._ . II- :11 1 _1 COOK STOVE I 1 IST 1f-. ..- f DIRECT VENT HEATER I ._3 1IlikNEIlitiiiiilld. • DRYER -- ' SSINO111111110.010MITIMISOPISIE. .1 FIREPLACE i S S 1 FRYOLATOR . I ., 11,11111111 � � FURNACE I_IL'_ 1I . ft.. .1MI �� � GENERATOR .. �� i��� . . �Q. � GRILLE ��i amir . ! INFRARED HEATER f_ II...,. __! _-11111.1A 011111111111,011111I ..J LABORATORY COCKS --'1 ._ . .1 . . 'Ma -3.. _•'�nteM.•._. ! 9).. MAKEUP AIR UNIT OVEN 1 ITf � ��.,_ T17-11:711 F. f _ � POOL HEATER ...__, ... _. ' .... SI ._ I J` ROOM I SPACE HEATER l .1.1I_...._J A�S'IIL ®S.,IIMMI , . 4 ROOFTOP UNIT 1-7-JE:!ETT -.• `f asnnsI-1 TEST t r.... . � INISI I V N WATEREN -I • ERM HEAT• _ I Ma a� 'SM ..: UNIT HEATER I� � � VI �SIMINKI --I 0 0 HER .. • _ I ��',1�� _.�-• 'o.,...•_.._A -:max• • I SIMMINSIMAIR I •1 - 1$ a —, ,a- I TI� : - l11I - - e INSURANCECOVERAGE . .- Ihave acurrent_ insurance policyor its sustantiquivalentwhich meets the requirements ofMGT,Ch.142 YESN00 I IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGEBY CHECKING THE APPROPRIATE BOXBELOW • LIABILITY INSURANCE POLICY+ OTHER TYPE INDEMNITYct BOND 0 OWNERS INSURANCE WAIVER:I am aware that the licensee{laes not have thelnsurance 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 9 AGENT 0 SIGNATURE OF OWNER OR AGENT • I hereby certify that all of the details and Information I have submitted or entered regarding the application ere true d accurate to the•est of my knowledge and that all plumbing work end InstallationsperfennedunderthepermltissuedforthisapplicationvillbeIncompll ce with all Pertinent provision of the Massachusetts state Plumbing Code and Chapter 142 of the General Laws. %iI ] NC PLUMBER-GASFITTERNAMEI STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MP0 MGF0 JPQ JGF0 LPGI® CORPORATION +s# 32819 PARTNERSHIP 0# 1 I1LLCD#C • COMPANY MAME: WlNSLOW PLUMBING&HEATING IADDRESS 8REARDONCIRCLE • • CITY 1 SOUTH YARMOUTH STATE L112,11p 4 ITEL 508-394-7778 FAX]508-994-8256 CELL WA 6EMAILI aaountspafile aiwlnslow•com . . by �V 4 .;gs • W clitm US.gOV/@rt Workers'Compensation][nsoranee Affidavit:Bunilders/Confiractors/Electriciars/nnmbers ,_ . •ApuloficantInformation' PleasePriat%eiribl9 :• v ' Name(Businesslorganiratloa/lndividual): E.c.W,r�s.oted �lumba 2.. to.4•`dw Q_ vit. t Address: i a.-uaitovi ' ` >L . • Cify/State/Zip:.'Sea f ' V ,•41•1 Os Phone if: 505.399,-117St • Are you an employer?Checkthe appropriate box: - Type of project(required): al on a employer with 70 4. 0 I am a general contractor anal 6. Dim constnrction ,employees(fall and/orpart-time)•* , have hired the sub-contactors ;.❑ I am a sole proprietor or partner. listed on the attached sheet t 7. 0 Remodeling ship andhave no'employees These sub-contractors have 8. 0 Demolition working forme in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. 0 We are a coiporat on and its 10.0 Electricalrepahs or additions required.] officers have exercised their 1•0Iamahomeownerdoing all work . right of exemption per MGL • 11,0 Plumbing repairs or additions • myself[No workers'camp. 0.152,§1(4),and we have no 12.0 Roof repairs . insurance required.]t, employees.[No workers' comp.insurance required.] 13.0 Other bay applicant that checks 6601 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 anew affidavit indicating sut ontractorsthat checkthisbox mustattached an additional sheet showing the name of the sub-contractors and'theirworkers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site }formation. .{{ {{'� w , • tsrzanceCompanyName' Anit+ri r'kirt/o11 1' r \_ .eit t ✓t• � • olicy#or Self-ins.Lic.it: ($DJ A • •1. '` • Expiration Date: (—)— ann • )13, ttn SiteAddress'a3 n 1�'0�' l C'�Adl t�rn,( City/State/Zip: baW 1,17 • teach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as requiredunder Section 2SA of MGL 0.152 can lead to the imposition of criminalpenalties of a ne up to$1,500.00 andlor one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fore Fup to$250.00 a da stthe violator. Be advised ,at a copy of this statement maybe forwarded to the Office of • tvestigations theDIAfor insurer,- .overage ve•rcal on. • t do hereby certify un e e ainsant penalties o pe jurythat the information provided above is true and correct. I tl • .. j • Date: lal3ilaol 1 wt ti tk• CT1N 31�e`171 Official use only. Do not write to this area,to be completed by city or town official • City or Town; Permit/License# Issuing Authority(circle one): . 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbinglnspector 6.Other Contact Person: •- Phone#:' S,3‘,.,‘ t