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HomeMy WebLinkAboutBLDG-19-003692 : g1 CITYI VetrWleiM\ 1 MA DATE' IIaJI15'1PERMIT# i3lob. _00 3672 JOBSITEADDRESSIS1 Lathe U led S',Y4f'fiakR'SNAMEI Ph,ll p ChDno,-1 GOWNER ADDRESS 1 5'011Ci JTEIISOP39r-/ 1373 IFAXI TYPE OR OCCUPANCY TYPE COMMERCIALQ EDUCATIONAL0 RESIDENTIAL PRINT CLEARLY NEW.0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YESO N00 APPLIANCES? FLOORS-' BSM 1 2 3 1 4 1 5 6 1 7 ' 8 1 .9 1 10 1 11 12 13 14 1.6"111 in - • . CONVERSION BURNER _- _BOILER BOOSTER • COOK STOVE DIRECT VENT HEATER , DRYER FIREPLACE ., FRYOLATOR - r FURNACE I GENERATOR = GRILLE .._ INFRARED HEATER, n LABORATORY COCKS MAKEUP AIR UNIT - - � OVEN _ _ POOL HEATER ROOM SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER _ - _ WATER'EATER (\") 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 Q+ 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 Q AGENT 0 °r{ SIGNATURE OF OWNER OR AGENT CD I hereby certify that ail of the details end 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 a with all Pertinent provision of the Massachusetts State Plumbing Code end Chapter 142 of the General Laws. w', PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE 11Fri SIGNATURE MP0 MGFQ JP JGF❑ LPGI❑ CORPORATION A#13281C IPARTNERSHIP©4 I LLC❑#' I COMPANY NAME'EF WINSLOW PLUMBING&HEATING I ADDRESS'8 REARDON CIRCLE I CITY (SOUTH YARMOUTH I STATE MA ZIP'02664 ITELI 508-394-7778 I FAX 508-394-8256 CELII N/A IEMAILraccountspayable anefwinslow.com • 1 • If �\ a Iib VVII41iVIIin.406.0 J lIJ4VU44IanOLiW , 1 _ Department oflndns/rtalAccidents 1 I j,1 Office of Investigations r_e(`_I� 600 Washington Street - '�Y Boston,MA 02111 a Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers • licant Information Please Print Let ibl une pithiness/Organization/Individual): t��Ow eil1 .I.. 0.s'• e. int. a idress: ; it •tan s.c t. r ty/State/Zip: 5c u.r '/pr k„ .ih phone#: NM-399-TM you an employer?Check the appropriate box: • riamemployer with 70 4. 0 I am a general contractor and I a emploTypo of project(required): ' employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction f I am a sole proprietor or partner- listed on the attached sheet t 7. ❑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. ❑ We are a corporation and its 1 0 Building addition required.] officers have exercised their 10.❑Electrical repairs or additions I 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' 12.0 OtheRoorepairs comp.insurance required.] 13.❑ ther rplicant that checks bok Hl 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 end their workers'comp.policy Information. in employer that is providing workers'compensation insurance for my employees. Below is the policy and job site :eon. ace Company Name: au is‘, A-4m 1 •-- •� {'{, • . n 4, tt...E #or Self-ins.Lic.#: I$a i A Expiration Date: 1-1— acm9 e Address: _ ufeai • t a copy of the workers'compensation policy declaration page(Showingtthe policy number l 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 r$250.00 a da a:ainst the violator. Be advised to t a copy of this statement may be forwarded to the Office of rations I the DIAfor insur:I - overage veriA on reby certify un—penalties o ,• a • �% ry that the information provided above is true and correct. ' . . Date: 1. . i act h Z - 777: :ial use only. Do not write in this area,to be completed by city-or town official • or Town: Permit/License# CNA ng Authority(circle one): lard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector.5.Plumbing Inspector her \ • act Person: \ Phone#: � \_I . N r e \ 1 4