Loading...
HomeMy WebLinkAboutG-14-990 ✓/ g_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK y,til CITY Vp'YMcit/-jh. I MA DATE 7/ �j //l PERMIT# 16'I``CVO JOBSITE ADDRESS/6' /7245car rA 4/-- OWNERS NAME -Z<Z //J c_r 1 . . J G OWNER ADDRESS WA/4iY)rj/rf1 ITELJapt 53-2p FAX TYPE OR • OCCUPANCY TYPE - COMMERCIAL__I EDUCATIONAL j RESIDENTIAL S-- PRINT / CLEARLY NEW:__1 RENOVATION: .P.7 REPLACEMENT: ,_I PLANS SUBMITTED: YES_1 NO a----• APPLIANCES T FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 ` _ • 1_.J,_._..JJ 1__I 1. I v, BOILERO _1__..__� Y J �+ BOOSTER � i _ l_ CONVERSION BURNER ,_ I 1I II ; �J _� _J_1 CO • (� DIRECT VENT HEATER . - J _ _J ._ .� _m 1__ -. -J -- ! . . 1 DRYER STOVE 11�_ J . __.. ._. _.._j �.__. J . 1_. __ J .. _� .. ..�� J . __,.' _. i n,t FIREPLACE .._i _ , lel _ _1 _...1... __1 __—J .. -_ -.._J t' I FRYOLATOR - ` _ FURNACEGENER GRILLEATOR aaa _ ZI INFRARED HEATER .1.111.111001/111.8===1.1.11:110 .1=1:1111111111 LABORATORY COCKS • MAKEUP AIR UNIT J J i t 1 OVEN Y� I . v7. POOL HEATER ROOM ISPACE HEATER _ . 1 ROOF TOP UNIT TEST .11.111 .__UI111.0111. ._- .111 UNIT HEATERM5 as— NIN UNVENTEO ROOM HEATER111111011110.111111111111111111111M1111.11111111111111111111111.111111111 -- --I WATER HEATER 1 i ,, OTHER S. ( .. E 1 . . 1 .. . ' . ._I ___ -_ 1 _..I . 1 - . I 1 — I — I .. 1 . L,_ _. I L. _ .1,.... J _. _ 1 ._.__l._. -_I____J_ .._.L. . .1 .. . ...J ....__J ...1 ._ .J_ _ .i. 1 .._._-1__ _..1 . .. I --_J_.._.._1 __J _ ._1 _ .. ..I .. 1. _.._.1 ._i ___...i . _ 1 . 1 INSURANCE COVERAGE I have a current)lability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LI NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY !1 OTHER TYPE INDEMNITY .1 BOND L. : 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. CHE r ONE ONLY\OWNE' .. A s 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 tru= : d a urate to i :best• owledge and that all plumbing work and Installations performed under the permit Issued for this applicatlo will be in complianc- h all P= inent pro • of the Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A WINSLOW LICENSE# 12298. ; SIGNATURE • MP c. MGF . i JP JGF LPG: .. . CORPORATION I# 3281 , PARTNERSHIP ...I# LLC .1# . COMPANY NAME E.F.WINSLOW PLUMBING&HEATING_ COfj ADDRESS 8 REARDON CIRCLE, _ CITY SOUTH YARMOUTH STATE MA ;ZIP 02664 'TEL 50R-394177R FAX 508-394.8256 ;CELL. :EMAIL ACCOUNTSPAYABLEOEFWINSLOW.COM RECEIVED • M • 19 0 1PT . .e I. . .. i ' BU fl DING DEPARTMENT r" By: ' -- -- iM The Commonwealth of Massachusetts w_= Department of Industrial AccidentsCs t "Mi_:/ Office of Investigations _I�_ � 1 Congress Street,Suite 100 —•-- Boston,MA 02114-2017 1.1 •,.•,'. wwxtmass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lealbly CJ Name(Business/Organization/individuat): 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.© a employer with 66 4. 0 I am a contractor and I egeneral 6. 0 New construction employees(full and/or part-time)." have hired the sub-contractors 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. 0 Building addition [No workers' comp. insurance comp.insurance. 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. [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 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�ifectie p/rins and p aides of perjury that the information provided above is true and correct. signature: Date:2°14 • 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 Authorlty(circle"one): 1.Board of H€alth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other a Contact Person: Phone#: