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HomeMy WebLinkAboutBLDG-19-003178 CITY r JOBSITEADDRESS',S(elt'I '13AM (irEltY0tm0d)'% IOWNER'S NAME[trin GOWNERADDRESS' come 1TE45043g4t131 Q IFAXE=3 nf� TYPE OR OCCUPANCY TYPE COMMERCIALQ �E,DUC/ATIONAL© RESIDENTIAL /,��Sinal//" PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:D' PLANS SUBMITTED: YES© NO[]+ APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _______ CONVERSION BURNER COOK STOVEa_ — DIRECT VENT HEATER DRYER r FIREPLACE FRYOLATOR - FURNACE - _ - - GENERATOR GRILLE INFRARED HEATER, y --- LABORATORY COCKS - " MAKEUP AIR UNIT e _- - � - OVEN _ _ - - POOL HEATER - ROOM I SPACE HEATER IS ROOF ROOF TOP UNITv TEST UNIT HEATER UNVENTED ROOM HEATER WATER FATE. =_-- — NS OTHER 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❑ 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 0 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 L.0 and that ell plumbing work and Installations performed under the permit issued for this application will be In comp)fl e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.) �J' - . u. ., cJPLUMBER-GASFITTER NAME STEPHEN A.WINSLOW '� J LICENSE^ 12298 � � SIGNATURE v MP0 MGFQ JP EI JGFQ LPGIQ CORPORATIONQ#'3281C I PARTNERSHIP©4 1 LLCQCLJ COMPANY NAME'EF WINSLOW PLUMBING&HEATING I ADDRESS'8 REARDON CIRCLE tP , CITY I SOUTH YARMOUTH I STATE MA ZIPI 02664 'TELT 508-394.7778 - -J I CI cp. -4 FAX 508-3948256 CELL)NIA !EMAIL)accountspayable(o�efwinslow.com T Y 1 �3 orrtyssls V tgIyUM4IOIp,4L{J - Department • • I"1� t nt of Industrial Accidents _1:�1_ Office of Investigations Ei;��_ � 600 Washington Street ' ? Boston,MA 02111 www•mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers licant Information C Please Print Le.ibl the(Business/organization/Individuai : (.:•f. f1 WIr1 OW YIl1.,vd• . � 0.�• ,, dress: ; •oi�cvj 71 a t a. ids y/State/Zip: co{vn „,,,,,,,{.L, ,,,fl. Phone fl: ___Wil- you an employer?Check the appropriate box: I am a employer with /0 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' 0 New construction) I am a sole proprietor or partner- listed on the attached sheet.= 7. Remodeling ship and have no employees These sub-contractors have working for me in any capacity, workers'comp.insurance, 8. Demolition [No workers'comp.insurance 5. 0 We are a corporation and its 1 Build ng a epairs required.] officers have exercised their 10.0 Electrical repo pairs or additions I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. insurance required.]t c. 15plo,§1(4),es. and wehaveno 12.0 ORoof ther pairs employees. [No workers' comp,insurance required.] 13.0 Other ilicant that checks bok NI must also fill out the section below showing their workers'compensation policy information. wners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. !ors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. t employer that is providing workers'compensation insurance for my employees. Below is the policy and job site pion. ce Company Name: jup tL 1 or Self-ins.Lk.#: I s a i A- r Expiration Date: —I— at _____29____ Ceyy,rvto- tl weal • C t"t , NI City/State/Zip:_ Op%7 a copy of the workers'compensation policy declaration page(showing 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 :o$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fond of a STOP WORK ORDER and a fine $250.00 a da a:ainst the violator. Be advised t I 4 t a copy of this statement may be forwarded to the Office of ations . the DIA for insur: - overage verij on. eby certify un • • I 'penalties a I. a �j ry that the Information provided above is true and correct. 1.- ' Date: I o1 I am” 'al use only. Do not write in this area,to be completed by city or town official rr Town: • p AuthorityPermit/License# JV g (circle one): trd oYHealth 2.Building Department 3.Ci ter t3 Town Clerk 4.Electrical Inspector 5.Plumbing Inspector i4�'� N. ct Person: • Phone#: •• e