HomeMy WebLinkAboutBLDG-19-002975 p - _r
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'rIl CITY VAtoMpUl'1n 1 MA DATE MITIM . PERMIT ft N46-�Q �dK 7�
JOBSITEfQY1DDRESSIIS HNa✓A/d 5/-. Yet Imtu�'�t 1OWNER'S NAMEJ f-KheMg 5✓entsnn I
G O "WNERADDRESS I 5& n4 ITEL SO$1CO35 IFAXI I
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIO '/$ R:SIDENTIALEC
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PO 'LANSSUBMITTED: YES❑ N00
APPLIANCES? FLOORS-' BSM 1 2 3 4 5 4: 9 9 10 11 12 13 14
BOILER _ a NM MIM NM
BOOSTER ME_ MilN ®
CONVERSION BURNER __ �l��
COOK STOVE .NM iiii _
DIRECT VENT HEATER S I -- _
DRYER NM
FIREPLACE 111
-
FRYOLATOR .
FURNACE — �-.. —
GENERATOR
• GRILLE
INFRARED HEATER, �.
LABORATORY COCKS
MAKEUP AIR UNIT _ ""
OVEN
POOL HEATER MOS
ROOM I SPACE HEATER
ROOF TOP UNIT - 111S1
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 Q NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY❑ BOND ❑
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.
0 CHECK ONE ONLY: OWNER❑ AGENT El
N 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 and accurate to the best of my knowledge
4, and that all plumbing work and Installations performed under the permit Issued for this application will be In compile :with all Pertinent provision of the
(O, :Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE - 12298 - SIGNATURE
Sc MP MGF❑ JP JGF❑ LPGI❑ CORPORATIONQ# 3281C PARTNERSHIP❑#) ILLC❑#I • I
etzt
O COMPANY NAME'EF WINSLOW PLUMBING&HEATING ADDRESS'8 REARDON CIRCLE
•
C'P CITY I SOUTH YARMOUTH I STATE MA ZIP'02664 ITELI 508-394-7778 I
. - FAX'508-394-8256 I CELL N/A EMAIL accountspayable@efwinslow.com I
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'9\ ausc viiia mucor.it-inns J ,v wea,..cauosru
Department of Industrial Accidents
1 Office of Investigations
C _,:4`— �; • 600 Washington Street
=�Y Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
.nnlicant Information
C Please Print Legibly
fame(Bus ness Organization/Individuaf): F•c• I pW
t elo,�v�roraq 8.tato.,,,, C'e� Int.
.ddress: 3' &eodtvi Grate. (J 0
ity/State/Zip:�auis� ,,t,,(t„ J.1,. Phone#: 5)8-39'j-1ti
-e you an employer?Check the appropriate box:
I am a employer with -70 4. Type of prefect(required):
0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New constructio
] I am a sole proprietor or partner- listed on the attached sheet._ 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. 9 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.❑Electrical repairs or additions
JI am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no
insurance required.]t employees.[No workers' 12.❑Roof repairs
comp.insurance required.] 13.0 Other
applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • _
reowners 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
motion.
ance Company Name: NJ-) 601V0.1 t l t a t n te_ Criunotkity •
y#orSelf-ins.Lic.#: Ial
�^ $ ' Expiration Date: (—I — a019111
iteAddress: n�rnw eJ.l-s nc Cc. .�1. t11
City/State/Zip: 0a467
:h a copy of the workers'compensation policy declaration page(showing the policy number and e,r iration r.
•e to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimi r penaltie : a
p to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ,E! 'ER and a I,e
to$250.00 a da a:ainst the violator. Be advised to t a copy of this statement may be forwarded to th- • -:\f
Ligations • the DlAfor insurar . overage vers .•on.
e((reby certify un eaims a penalties o r-jury that the information provided above is true and correct.
uTa c.• - _ . Date: la i aoi'
#: .Sv4.31`1- 777$
?alai use only. Do not write In this area,to be completed by city,or town official
•
y or Town: Permit/License#
•
sing Authority(circle one):
board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector \
)ther 4--
ttact Person: -----CC.%
Phone#:
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