HomeMy WebLinkAboutBLDG-15-000013 ✓ \r ✓ v.
L MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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" =.t CITY JUy rrn"' ' "1' MA DATE?34 / JPERMIT# b/o 0
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JOBSITE ADDRESS < / $,nfe «yOWNERS NAME C/ QnIt
GOWNER ADDRESS /7 Aln5e/Wet-- G";..,6 /• EL .carr -7 - IFAX .J
TYPE OR
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OCCUPANCY TYPE COMMERCIAL; EDUCATIONAL JI RESIDENTIAL[��
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NEW:....i RENOVATION:'_.) REPLACEMENT:gf PLANS SUBMITTED: YES__1 NO ._
APPLIANCES I FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER J — ..---..--- I , _J_- 1 I f , .J
BOOSTER _____ JI J I J _I _I 1 ,--E _ __..1
CONVERSION BURNER ' J }—__I _,_ _!
COOK STOVE _ _IA_ I' _ _ I, ._ I . _J . _ J_ _. _J _IL___ I _ __ 1
DIRECT VENT HEATER .,_I __ . _ __J___,,_l I'' _-.11. __J_.. J' ---1 -_. J
DRYER . _J J_. _ _—I _J J__ 1 . __.J - - ---- -------JrJ ___. 1 .-
�/ FIREPLACE -
V FRYOLATOR
FURNACE ___J J__.1:LI rirJ... J__..-_l -J ___J_. __J _J —. J _;
GENERATOR ____J i.._1_ _.-.-_4_____(..._....,I ---1 ,_.
GRILLE 1 1 I 1 I li I ,1,.__J .J , ..f, , ..;
INFRARED HEATER _J 1 ! J I
LABORATORY COCKS I . M .. ..1 J
MAKEUP AIR UNIT _J _,,,_ f , _„-J ,,..1 _ ,_,J
OVEN �� J _ _-. I J .__
POOL HEATER _ ..___I._.w , J __J _ _1 _-._JL_-___;
hROOM/SPACE HEATER _I _,e.-1 J
ROOF TOP UNIT J 1_ 1
TEST 111.111111.101101111MallatillIMISMINI _ . Jiiili
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JUL 03-2014 J
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BUII.DIN 1 INSURANCE COVERAGE
..`, ..- , - Trance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ILI NO . i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 'J OTHER TYPE INDEMNITY .-,J BOND I_J
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 co 8 ` ': OWN R _.J AGEN.
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. -• r e to th best of my edge
and that all plumbing work and Installations performed under the permit issued for this application will be in compliance wi Perti nt provision l• e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW , LICENSE# 12298. SIGNATURE
MP :1 MGF .,. I JP _. JGF _ LPG/ __, CORPORATION ;# 3281 ; PARTNERSHIP _I# J LLC _J# _., -
COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING Cod ADDRESS 8 REARDON CIRCLE_
CITY SOUTH YARMOUTH ' STATE MA ZIP 02664 :TEL 508-394-7778
FAX 508.394.8256 ICELL_.,, /EMAIL ACCOUNTSPAYABLE EFWINSLOW.COM
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The Commonwealth of Massachusetts
Department of Industrial Accidents
lE_s9illi_ i Office of Investigations
• _` s t- � 1 Congress Street,Suite 100
Boston,MA 02114-2017
•:., 4 wwwmass.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
employees(full and/or part-time).* have hired the sub-contractors 6. ElNew 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• t 9. 0 Building addition
[No workers' comp.insurance comp.insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
'3.0 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.]1 c. 152,§I(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box al 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 entitles 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 andJob 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.
•_- •
Ido hereby certify un e pnyand pe allies of perjury that the information provided above is true and correct
Date:
k+ 2014
Simature: «.. .._.-
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 aerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: