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HomeMy WebLinkAboutBLDG-19-002970 S_ `i.Lr 1=,E CITY Yurrtmih-- IMA DATEII2 I['S E PERMIT# /1'LI�b-%9-40aa 0 O +1'. JOBSITE ADDRESSI-32 riL1Oc Rd 0,4 Ya/moth 0a613I OWNER'S NAME I V ;rad 7(4,n con G OWNER ADDRESS I Simi I TEQ 508115 Li 61 a IFAXI TYPE OR OCCUPANCY TYPE COMMERCIALQ EDUCATIONAL Q RESIDENTIAL PRINT / CLEARLY NEW:Q RENOVATION:❑ REPLACEMENT:LT PLANS SUBMITTED: YES© NOD APPLIANCES T FLOORS-) BSM 1 1 2 3 4 I 5 ' 6 7 8 9 10 11 12 1133 1144 BOILER -_ — BOOSTER _it- nisamirai , CONVERSION BURNER ower COOK STOVE __ z - — DIRECT VENT HEATER - — - -. DRYER FIREPLACE FRYOLATOR _ - - -- FURNACE GENERATOR - _ - _ GRILLE - INFRARED HEATER, _____ LABORATORY COCKS MAKEUP AIR UNIT _ OVEN POOL HEATER _ _ __ _ _ _- ROOMISPACEHEATER ROOF TOP UNIT TEST UNIT HEATER _ UNVENTED ROOM HEATER - - WATER -_TE 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 Q I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY CI OTHER TYPE 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 ray signature on this permit application waives this requirement. c-D CHECK ONE ONLY: OWNER 0 AGENT 0 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 and that all plumbing work and Installations performed under the permit Issued for this application will be In compll with all Pertinent provision of the 10 , Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �1di PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE � � MP El MGFQ JP El JGFQ LPGIQ CORPORATION 0#13281C IPARTNERSHIP©#I ILLCQ#I • I � 0 COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESSI 8 REARDON CIRCLE t.:5:)d7) CITY I SOUTH YARMOUTH I STATE MA ZIPI 02664 ITELI508394-7778 SSI FAX 508-394-8256 CELLI N/A IEMAILI accountspayableno,efwinstow.com I+ S\ .NOG VVIICIIlo.f,re..006I0 J IISWJ.CYI6t4,{.6I. ' w= Department of Industrial Accidents �• �, .GMt A slit . Office of Investigations -_.ti`_ 600 Washington Street = (Y Boston,MA 02111 % www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Lpplicant Information ' Please e Print Legibly l fame(Business/Organizationfndividual): E.c.Wtk'0W QIu� S �ta1 eel In{. .ddress: g Q eoatin (That . ity/State/Zip: Sc,ikvn Ytrs'-r,,Ain NA- Phone II: NYS-399-1??4 e you an employer?Check the appropriate box: rI am a employer with "70 4. 0 I am a general contractor and I Type of New projectn (required): ): employees(frill and/or part-time).* have hired the sub-contractors 6. ❑ construction J I am a sole proprietor or partner- • listed on the attached sheet 2 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 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 10.0 Electrical repairs 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 insurance required.]1 employees.[No workers' comp.insurance required.] 13.0 Other applicant that checks box ftl must also fill out the section below showing their workers'compensation policy information. wowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. ante Company Name: ni o .a c-L y#or Self-ins.Lie.#: '($a I A ^ Expiration Date: i-1— ao19 ite Address: �cfrYwwlyrEwl{•y� in Ctr,4,k�1. t 1% City/State/Zip: Dao to 7 is a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). :e to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a p 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 to$250.00 a da a ' st the violator. Be advised t..t a copy of this statement may be forwarded to the Office of ....*ii. agations the DIA for insure, - overage veri"on. ereby certify un • e aims a /penalties o •jury that the information provided above is true and correct. A- : — .iDate: t • i 31 I nit #: .bt 3t4• 777k ?tial use only. Do not write in this area,to be completed by city or town official • • y or Town: Permit/License# • ting Authority(circle one): \ loard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector )ther \---...C.\,t,q) 'tact Person: Phone#: • r