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HomeMy WebLinkAboutBLDG-19-003522 'tie n' CITY' VA=�p1_ I MA DAT:MEM PERMIT# lain/�!gfa1 JOBSITEADDRESS' Sconce IOWNER'SNAMEI ti OMR 640105 I G 'QWNERADD SS(3O( Bock_s/and Rd aliI- 18Wes/ ITEII5081itc15 IF I I TYPE OR 1"114/141OCCUPANCY�6E; COMMERCIAL❑ EDUCATIONAL RESIDENTIAL CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:9' PLANS SUBMITTED: YES❑ NOD - -- - ---- .-- �, _ - - �S APPLIANCES? FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ _ r BOOSTER �. __ - CONVERSION BURNER �, 000K STOVE ant DRYER FIREPLACEincur 111 - �. - — FRYOLATOf2 . FURNACE GENERATOR --_ - -. GRILLE - INFRARED HEATER, LABORATORY COCKS _ MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER 1 ROOF TOP UNIT TEST - IIINIMUISI - - UNITHEATER _ UNVENTED ROOM HEATER WATER EATER r= -- OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 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 my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER❑ AGENT❑ 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 an 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 compllan with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.al � aaip.,e_../ V PLUMBER-GASFITTER NAMEI STEPHEN A.WINSLOW ILICENSE 12298 SIGNATURE CI rk MPD MGF❑ JP I:1 JGF❑ LPGI❑ CORPORATION❑+ #I 3281C .I PARTNERSHIP© ILLC❑#I ' I rt. COMPANY NAME EF WINSLOW PLUMBING&HEATING I ADDRESS'S REARDON CIRCLE I - er CITY I SOUTH YARMOUTH I STATE MA ZIPI 02664 ITELI 508-394-7778 I = .r' FAX'50B-394-8256 I CELLI N/A EMAILI accountspayable@efwinslow.com I E 5'0 � • R3 Mause •.vrrar.wrsrve.ars,e J•ra.auoaaasanrsw lm t. —=_` / Department of Industrial Accidents ,- Office of Investigations. 1%1 Ili I�'`_r; -600 Washington Street 1/4„.—toBoston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers i licant Information Please Print Le.'131 e(Business/Organization/Individual): 4 cetviijI C imOW QL13 .. j 0. , - ,' e. f9{. I Idress: v. -ntinri 't Q„ i ty/State/Zip: 5ov � Phone#: IU8-3q9- '1']4 you an employer?Check the appropriate box: er with 70 4. 0 I am a general contractor and I ri am a employ of project(required) employees(full and/or part-time).* have hired the sub-contractors 6: ❑New construction I I am a sole proprietor or partner- listed on the attached sheet.t 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 1 ❑Building addition required.] officers have exercised their• 10.❑Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.0 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' 13.9 Other comp.insurance required.] iplleant that checks boz#1 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. etors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. n employer that is providing workers'compensation insurance for my employees. Below is the policy and job site cation. i ace Company Name: Nu ie‘...3 t 10 r #or Self-ins.Lic.#: _$ �llr a l �^ Expiration Date: (—j— aoiA eAddress:j COtyv. v,,e,a{{y� t L 1 Al"iili / a City/State/Zip: 03467 i 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 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 i$250.00 a da a.ainst the violator. Be advised ti.t a copy of this statement may be forwarded to the Office of rations r the DIA for insur.r-- overage yeti"on reby certify u penalties o ,•ju '....., k' � ry that the information provided above is true and correct. 2: • / . _.41h,_ Date: 1? . 1 as I: 11 e lic-797: *fuse only. Do not write in this area,to be completed by city or town official • or Town: • Permit/License# ng Authority(circle one): +� lard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector \ her act Person 0 Phone#: •• t