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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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INSURANCE COVERAGE II
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. h.142 Bat l " ,
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW By Ptc
LIABILITY INSURANCE POLICY !.1 OTHER TYPE INDEMNITY BOND I_..^ ,V-rt 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the p V
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE 0 : OWNE• . I AGENT ...
SIGNATURE OF OWNER OR AGENT .. a
I hereby certify that all of the details and Information I have submitted or entered regarding this application are true a • .ccurat= to the b: t of my k
and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance wi all -ertine provision . ,
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1..---
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW • . • ' ;LICENSE# 12298- SIGNATURE
MP L1 MGF _..i JP ..: JGF _ , LPGI __J CORPORATION . ;#. 3281 i PARTNERSHIP _1# 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 , I EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
The Commonwealth of Massachusetts
_ Department of Industrial Accidents
Pre—..?+t+i= / Office of Investigations
_' l= 1 Congress Street,Suite 100
E%=i =_ Boston,MA 02114-2017 .
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"'+.,,�,� www.mass..gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
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? Check the appropriate box: Type of project(required):
1.0 I am a employer with 66 4. 0 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
listed on the attached sheet. 7. 0 Remodeling
2.❑ I shipm a sole proprietorenomor partner- These sub-contractors have J
and have no employees 8. ❑Demolition _ ,
working for me in any capacity. employees and have workers' 9. ❑Building addition
[Noeworkers' comp.insurance We comp.'��or't
10.0Electrical r airs 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 MGL 12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no 13.0 Other
employees. [No workers'
comp.insurance required.]
'My applicant that checks box NI 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.
:Contractors 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 it providing workers'compensation insurance for my employees. Below is the policy andJob site
information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Policy#or Self-ins.Lic.#:
1764A Expiration Date:O1/01/2015
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.
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I do hereby cerafy uacdeuhep ins and p allies of perjury that the information provided above is true and correct
(^�/\1J /
,Signature: F Date:2014
h. p
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phone#: 508-394-777
3 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#: