HomeMy WebLinkAboutBLDG-15-000327 _g , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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APPLIANCES
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JUL . Lun INSURANCE-COVERAGE
I ave a curveY-f`Ar'i'msNT ra a policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1.±.1 NO _.i
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(vDRRU CHECKED YES • DICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY +J OTHER TYPE INDEMNITY ...1 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.
CHE ONE ONL • OW • ._.J AGE r 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 a • as rate t•the best of m edge
and that all plumbing work and installations performed under the permit Issued for this application -II be In compliance • all P:rtinent provlsio i • the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW LICENSE# 12298. 1 SIGNATURE
MP ±i MGF _.1 JP JGF ,_; LPG' CORPORATION :# 3281. _ __ _j PARTNERSHIP _I# . .,1 LLC ._I# '
COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING COQ ADDRESS 8 REARDON CIRCLE._ '
CITY SOUTH YARMOUTH, I STATE MA ZIP 02664 'TEL 508-394-7778
. FAX 508-394-8256I CELL. , :EMAIL ACCOUNTSPAYABLE(dEFWINSLOW.COM -,___ i
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The Commonwealth of Massachusetts
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Department of Industrial Accidents
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k.Mgt=` !—G/ Office of Investigations
_.;�,�_ �0 1 Congress Street,Suite 100
Vii 11._—= MA 02114-2017
"',a =,,,, www.massigov/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. I.
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH,MA 02664 Phone#:508-3944778
Are you an employer?Check the appropriate box: Type of project(required):
1.11.1 I am a employer with 66 4. 0 I am a general contractor and I
employees(full and/or part-time).
s 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
working for me in any capacity. employees and have workers' 9. ❑Building addition d
[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 Q
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.]
*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 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 51,500.00 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 un4erlhap ins and p allies of perjury that the information provided above is true and correct
Signature: C. ' / Date:
2014
Phone#: 508-394-777 /// 1�...—
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#: