HomeMy WebLinkAboutBLDG-19-003398 e gFer
eet CITYI ?4!m,ftl,th I MA DATE fl/3o / . PERMIT#*4&_/9nl&
.s-
JOBSITE ADDRESS I , 'a , . 6r, , ! ,int „, OWNER'S NAME I Cit art (ooK I
G OWERADDRESSIplROIL6r: 15ostfb a,mol 1, An.66y I TEI 6Og24O92I2 )FAX( i
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:D PLANS SUBMITTED: YES❑ NOD
APPLIANCES? FLOORS-+ BSM 1 2 3 4 1 5 1 6 1 fit 8 9 1 10 1 11 12 13 14
BOILER --- _ - -
BOOSTER - -
CONVERSION BURNER - — ---
-
COOK STOVE - ' `
DIRECT VENT HEATER — ' -- -
DRYER
FIREPLACE - _ - -— ”
FRYOLATOR
_FURNACE
GENERATOR
INFRARED HEATER,
LABORATORY COCKS __
MAKEUP AIR UNIT z
OVENi •
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER-)EATER
OTHER ilaitill — —
®: _ -
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 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.
CHECK ONE ONLY: OWNER 0 AGENT 0 -
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 compliann-with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
O PLUMBER-GASFITTERNAME)STEPHEN A.WINSLOW (LICENSE# 12298 SIGNATURE
C...) MPD MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION Q# 3281C PARTNERSHIPD#I ILLI❑#I
cr 0 o COMPANY NAME)EF WINSLOW PLUMBING&HEATING ADDRESS)8 REARDON CIRCLE
CITY [SOUTH YARMOUTH I STATE MA ZIPI 02664 ITEL I 508-394-7778 I
S FAX)508.394-8256 I CELLI NIA )EMAIL)accountspayableno,efwinslow.com
69
•
(4(4
'Lt S M. YVIIY/W/.t,44µ/O y 1.{SS..V{{../.0[n"..
Department of Industrial Accidents
y1IB. ' Office of Investigations ' "
V 600 Washington Street . '
- Boston ,MA 02111
'
� `� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Luplicant Information
EC.
Please Print Legibly
fame(Business/Organization/Individual): E. .Wtys'pw 00.4 li%te-t'-•,
lite- es)1nt.
ddress: g Latin clap_
ity/State/Zip:�at /rXi�[ Yt� p Phone#: 503-394-117St
: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 project(required):
employees(full and/or part-time).* have hired the sub-contractors 6' ❑New construction)
3 I am a sole proprietor or partner- listed on the attached sheet.t 7. [1]Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance.
[No workers'comp.insurance 5. 0 We are a corporation and its - 9. 0 Building addition
required.] officers have exercised their. 10.0 Electrical repairs or additions
3I 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'
comp.insurance required.] 13.0 Other
applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
leowners 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
mation.
ance Company Name: its 00 c10 7-,
y#or Self-ins.Lie.#: 'I_ al A-
Expiration Date: i"QMi
ite Address: Gesnman k rea_( t a COA �a
City/State/Zip; 0,.,,.
:h a copy of the workers'compensation policy declaration page(Showing the policy number a,d ed a ion date).
•e to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crim 'al 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 0' a ER and a fine
to$250.00 a da a:ainst the violator. Be advised ti.t a copy of this statement may be forwarded to the Office of
:igations • the DIA for insure., . overage veri a' on.
ereby certify un a ains a penalties o p•jury that the information provided above is true and correct.
. " S. Date: la t olOF
#: 1 - 777: tom,
?dal use only. Do not write In this area,to be completed by city,or town official e
•
•
y or Town:
Permit/License# •
ring Authority(cirdeone): —t�� ,
board of Hea•
lth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector \
)ther • .
'tact Person: k\
Phone#: • �`
1