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Home My WebLink AboutBLDG-15-003089 ../........" - ' __j MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •fsn re ait / //�� } p- N—.0 CITY Rrjne J/ih ___ girl _I MA DATE/011k/..-.I PERMIT#L7�.b&45't308y JOBSITE ADDRESS/9 ha I/LQ • l OWNER'S NAME _ ' (.1? � OWNER ADDRESS r \� I / . / TEL 7�19�._ .-..FAX— .__I 1J TYPE OR OCCUPANCY TYPE COMMERCIAL, EDU ATIONAL _J RESIDENTIAL PRINT t\t\. CLEARLY NEW: RENOVATION: ,...1 - REPLACEMENT: .) PLANS SUBMITTED: YES_,J NO :... .APPLIANCES 1 FLOORS—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 ^J BOILER �.e_._I.,- - ___ . , ...._._J__ ... ...ii.__ 1 -_J_ .,_ -L_ Ni) BOOSTER ____I'___.J . J . J J.___ ___J'__J _.J CONVERSION BURNER __,_f__Ji .TJa _rJ_J_�J _1, J __L__J COOK STOVE J__ _ I —, J ....J I_.•_..J _J_. 1 _..1 1_,. .1 0 DIRECT VENT HEATER J_ J . J® J .__I J ___J J -_ 1 J _J DRYER ._.J _. J _..i i J_ -- i 1 . _ I 1 .. I I •_ _ .. ' FRYOLATOR - ®__ -J i . Ng GENERATOR v_ GRILLE J r INFRARED HEATER 1 _ J __J _ lI LABORATORY COCKS JJ110.1J 11.11J�;� J ] ( -1111111.1 MAKEUP AIR UNIT MNll. flinitill�NIMIP OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT __ UESTNIT — J„___. ] .1 . Ii� UNIT HEATER ----1 J__ J UNVENTED ROOM HEATER -J ' _Jfi_iMtn®®M®®j _, 1 WATER H(Ajfj�in2axe�I flEwa J a J il®®_ J® OTHER (Lic--^^t '7]?-??.!„4,. a _1 1 I I _ J AL-J1.1 , _I J 1 -. 1 : . J_ 1 _ I I i - _ _I I - I _- J . I .___ I J . I I /pA dT _ 1 _.i -1 _ __I 1 __. 1 .- I _____ I.____i _ ._l -. _I - ' V - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Id NO , I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY .fi . OTHER TYPE INDEMNITY .J BOND I_.i 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 01 Y: OWNE' ....1 AGE1 i 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 -•. aceur. e to th=best of mg" ledge and that all plumbing work and Installations performed under the permit issued for this application will b:to compliance w • , I Perti nt provisi. the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. As.... PLUMBER-GASFITTER NAME STEPHEN A WINSLOW , LICENSE# 12298_ I —. SIGNATURE MP +1 MGF __i JP JGF __; LPGI __-; CORPORATION '# 3281 I PARTNERSHIP _..I# I LLC I# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING COd ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394.7778 FAX 508-3948256 :I CELL !EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM , • 0g • • The Commonwealth of Massachusetts w== Department of Industrial Accidents 1 _:'lith- l Office of Investigations - ml= y , ._. 1 Congress Street,Suite 100 � p Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E.F. WINSLOW PLUMBING & HEATING CO.,INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-39417778 Are you an employer?Check the appropriate box: 4. am Type of project(required): 1.0 I am a employer with 66 0 I a general contractor and I employees(full and/or part-time).*.- . have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition workingfor me in anycapacity. employees and have workers' P ty• 9. ❑Building addition [No workers' comp. insurance comp.insurance.: 10.0Electrical repairs or additions required.] 5. 0 We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MOL 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box 111 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that chock this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and Job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lie.#: 1764A Expiration Date:01/01/2015 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up 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 of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un p ins and p allies of perjury that the information provided above is true and correct 2014 $ienature: / Date: • Phone#: 508-394-777 • Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: