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HomeMy WebLinkAboutBLDG-19-003408 .1.±-064.1e; =n ; t, `:WV- t CITY I TA/l3� t 1 I MA DAT 4.11M71 PERMIT# /gG/��Y/Q--!/O rid c JOBSITEADDRESS � ,Pin�rrnlln� kil8Sit, IOWNER'SNAMEI Q0vyla5 Rob%"n�soi, 1 G YOINERADORES 4'1t v ITEM 3`2 975 1 IF^^f OWNERADDDRESS ISnine TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES© NO❑+ APPLIANCES 1 FLOORS-1. BSM ' 1 2 3 4 5 6 7 6 9 10 11 12 13 14 BOILER BOOSTER MS - CONVERSION BURNER COOK STOVE „ _ . __ - DIRECTVENTHEATER =a- _ —__ - � DRYER - FIREPLACE . = -_-- ” FRYOLATOR - FURNACE GENERATOR GRILLE _ - INFRARED HEATER, LABORATORY COCKS - -- - •••••••••.,,mmi.,,.0,,,.sank_�.. ... -._ MAKEUP AIR UNIT OVEN . , -- - POOL HEATER _ __ ROOMISPACEHEATER ROOF TOP UNIT TEST - -_ - 1 _..-r . 's . m UNIT HEATER UNVENTED ROOM HEATER _ m WATER HEATE- OTHER NIMIS — 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. 1/40 CHECK ONE ONLY: OWNER 0 AGENT❑ lt 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 `f` and that all plumbing work and installations performed under the permit Issued for this application will be in corn co with all Pertinentrt/ provision of the Le) , ;Massachusetts State Plumbing Code and Chapter 142 of the General Laws. corn U PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE iiE 12298 ' SIGNATURE MP ID MGF❑ JP ID JGF❑ LPGI❑ CORPORATION❑+DI 3281C IPARTNERSHIP❑tar ILLC❑#I - I :: ifl COMPANY NAME)EF WINSLOW PLUMBING&HEATING IADDRESSI8 REARDON CIRCLE CITY I SOUTH YARMOUTH I STATE MA ZIPI 02664 ITELI 508-394-7778 I 4) r- FAX 508-394-8256 I CELLI N/A IEMAILI accountspayable@efwinslow,com •. 00 bed- Sas\ a In' "'innetn"rcuass vJ iraauoms,.,..o,..,,, Sriltrar Department of Industrial Accidents .51011=51/, Office o ( 411Eflnvestigataons _ - !i`_ � 600 Washington Street '�. ,ta� . Boston,MA 02111 www.mass.gov/die Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers licant Information C Please Print Le'ibl title(Business/Organization/Individual); d..•T�^.L1�ty �IOW j� k -s4174 Idress: "; ,',•oad i 7.r ' Q. I ' ty/State/Zip: as NA Phone#: [)b-39y-]'hQ you an employer?Check the appropriate box: (req4. 0I am a general contractor and I ri am a employer with -70Type of project ructiored)i employees(full and/or part-time).* have hired the sub-contractors 6' New construct on 7. Remodeling I I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub-contractors have working for me in any capacity, workers'comp.insurance. • 9g' ❑Demolition [No workers'comp.insurance 5. 0 We are a corporation and its - 1 Building repairs on required.] officers have exercised their. 10.E Electrical 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•0 Roof repairs required.]t employees.[No workers' comp.insurance required,] 13.0 Other wlicant that checks box ill 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. ctors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'conip.policy n employer that is providing workers'compensation insurance or m employees. Below u the olio and job site nation. f yp Y ace Company Name: Ni l o%a ; itveA �--- #or Self ins.Lic.#: I$a i tt Expiration Date: 1H— ao9 e Address:_ wee! , C kit, , FillCity/Staterzip: 44ye7 t a copy of the workers'compensation policy declaration page(§howing the policy number and expiration date). to secure coverage as required under Section 25A of MGL 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 { )$250.00 a da a;ainst the violator. Be advised t, t&copy of this statement may be forwarded to the Office of nation • the DIA for insure, - overage vert"on. reby certify u penalties ou "! ry that the information provided above is true and correct. . S '--• ?: 4 or / .� Date: i ao " is 1► .• -777: :tel use only. Do not write In this area,to be completed by city,or town official • or Town: Permit2icense# ng Authority(circle one): lard of Health 2.Building Department 3.City/TownClerk 4.Electrical Inspector 5.Plumbing Inspector her `,...\.-%%;%\ act Person: Q Phone#: \ e Ni