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HomeMy WebLinkAboutG-14-979 •e< _� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ¢el,1m CITY Ya4 /7,tier),/. .._...._. 1 Fl1_..!/.:�T ,PERMIT# b7'/— 7 _ JOBSITE ADDRESS *7-7 Q OWNER'S NAME (2Q- j qty G _ �./�'-/r� _ .. ..._ - 1 OWNER ADDRESS L�Cwt jOWN 1TEL 9SI3f0}`"ZJFAX ._ ... .----.: j TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL j EDUCATIONAL •_ (1— 1 RESIDENTIAL_ CLEARLY NEW:.„,1 RENOVATION: ...I REPLACEMENT:-_.c PLANS SUBMITTED: YES_.J NOLs 47,4 APPLIANCES 1 FLOORS--0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER , BOOSTER _____l_ f J l .___11 i -J-- 71...___J... f _ _J CONVERSION BURNER __ I 1 COOK STOVE f __J—. I L _. -J 1:_ --� _{--.._1� -J i DIRECT VENT HEATER �_i ]`_"` J DRYER - _J J ._._.J_ J J _J__ J .. _- J _ 1 __.1 . _..._i J I FIREPLACE __J __ J __.J _- _I . ___J .._J_ _ _.T J.__ _ J . I FRYOLATOR _.•_..J _..1 ._. kI _�. }I _I -_.J_ 1 J. .-.1 j 1 .. J _, FURNACE _1 J_ _J J �._J'___ t _1 _ 1__.._ _ _1 L_-- - GENERATOR I'._— i j 1 J . .. GRILLE I 4 -L _.J JalI I INFRARED HEATER ' � LABORATORY COCKS I MAKEUP AIR UNIT — _-J 1 _ ._J, I. � . .. - I 1 OVEN 1 _ .._J....,.._J ._. J _ _1 i. _J _ . 1 - I POOL HEATER __.J 1 . f .__I I l ROOM ISPACE HEATER ,-._I I J , 1. . I, ._J._._J ._rl_ , . .. ; ROOF TOP UNIT e_J ,' I I . __w1_ _. _I m i,,._ I TEST UNIT HEATER ___1___ _ __J J n , 1 ._ . 1 I__ J_._ l _._ i' _ __I __.1 UNVENTED ROOM HEATER . _„ J _J __'____.1.1' ___J.,_J 4 J __ _J _ 1 J _ JUIN _ .I., _ i _. I J WATER HIM-ER _ .-i _J i_... ._J—1 J I_. I _ . „ J _J___. I . OTHER QS 7if-2_�i. / 1 J . _ ' —1 - J i_ I . J r I 1 _1. I I 1 i I 1 1._ I . 1 . 1 _. I . ___.1. t. _J...__ ._t. _J _. 1 _._-.J J ' 1 1 J .._1_ _J. _._-I _ _.I _._._._..1,_J __. .J .... ...I I._..._.1 . J-. : INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I!1 NO ' I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 4.1 OTHER TYPE INDEMNITY BOND 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 ONLY: OW ..t A ' 1 . 1 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 a accurate to a best of . owledge and that all plumbing work and installations performed under the permit Issued for this application wi I be In compliancy all Pe 'nent provi• • of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. rt" PLUMBER-GASFITTER NAME STEPHEN A WINSLOW LICENSE# 12298 ; SIGNATURE MP !: MGF . i JP . .. JGF ,. , LPGI . CORPORATION ;# 3281 . PARTNERSHIP .._J# I LLC .1# COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING COj j+ ADDRESS 8 REARDON CIRCLE • - CITY SOUTH YARMOUTH ' t STATE MA ;ZIP 02664 'TEL 506-3R7E__L' E IN.E FAX 508-394.8256. . CELL , IEMAIL ACCOUNTSPAYABLEaEFWINSLOW.COMCJc22ga. 46(� I # 1 MAY 152014 I �p IC ©UILDING D28/LRTMENT ' f`!T V��if� ✓ 0 -70 The Commonwealth of Massachusetts C Department oflndustrialAccidents 1+_,fill,_; Office of Investigations "'1 1 mirk= -y 1 Congress Street,Suite 100 a '- _•� r a Boston,MA 02114-2017 ".-,:'�" wwntmassgov/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#:508-394-7778 Are you an employer?Checkthe appropriate box: Type of project(required): 1.0 I am a employer with 66 4. 0 I am a general contractor and I employees(fuli and/or part-time).* have hired the sub-contractors 6. 0 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• insurance.: 9. 0 Building addition [No workers' comp.comp. insurance P• required] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 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 MGL 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#1 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 check 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.Lic.#: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 un4er chap ins and p allies of perjury that the information provided above is true and correct 2014 Sienature: i /r-" � / 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#: