HomeMy WebLinkAboutBLDG-19-003995 • _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'F '�c.,`lti zL CITY I t figti 7-t (i s r) MA DATE/7/2 67/3 I PERMIT#/9.<Db/F-CCIS
JOBSITE ADDRESS Ft tientree St4 AJ . OWNER'S NAME 102/0q,4,2,0 C/zEa)
GOWNER ADDRESS SI�e•-• ,TEI{508ITS•57ZO FAX -
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL®
PRINT
CLEARLY NEW:El RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO0
APPLIANCES 7 FLOORS-' ' BSM 1 2 3 4 5 ' 6 ' 7 8 9 10 11 12 I 13 I 14
BOILER 11 ( 4 1 11 I
1 If
�
BOOSTER I
. CONVERSION BURNER n;a,
COOK STOVE
DIRECT VENT HEATER 1,111111 ,.. 1
DRYER R 1
_ ,
FIREPLACE
FRYOLATOR
FURNACE / -,- _ fi - _
GENERATOR 7
GRILLE
INFRARED HEATER r
LABORATORY COCKS -
MAKEUP AIR UNIT
OVEN
POOL HEATER '
ROOMISPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER _
1 OTHER f
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0
N I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 10 OTHER TYPE INDEMNITY ❑ BOND 0
0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1)•••. Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are tr and accurate tor the best of my knowledge
end that all plumbing work and Installations performed under the permit Issued for this application will be In corn ante with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
�f rURE
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE
MPE MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION Q# 3281C PARTNERSHIP 04 ILLC❑#
0o
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL NIA EMAIL accountspayable@efwinslow.com
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w— Department of Industrial Accidents
t =_.aili_= i Office of Investigations
tti-'0n= 600 Washington Street
=fT1 Boston,MA 02111
• .: www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� I ' Please Print Legibly
Name(Business/Organization/Individual): C.C.Ww„$IOw Ytu,,.jot-•1 L 0co-t,.nq Qe., In(,
Address: 7' (�p��„ t^,tatL a (1X
City/State/Zip: Sour Yent-40,14n (4- Phone#: '533-3911-117cj
Are you an employer?Check the appropriate box: Type of project(required):
Xam a employer with 70 4. 0 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
1.❑ I am a sole proprietor or partner- listed on the attached sheet.t ?. ❑Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We area corporation and its
required.] officers have exercised their ]0.❑Electrical repairs or additions
1.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.] 13.0 Other
thy applicant that checks box/II must also fill out the section below showing their workers'compensation policy information. .
Homeowners who submit this affidavit indicating they are doing ail work and then hire outside contractors must submit a new affidavit indicating such.
:ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation. /n�
isurance Company Name: Marty,-t Cii k-ve,2 J`cnrtt n t aconin ly
olicy#or Self-ins.Lic.^#: 1 S a I it Expiration Date: ‘—I ^ aol9
,b hGe Site 1wea- 4h int-el CFegkAA I'1 U City/State/Zip: D,?'4to7
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). _ l
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a \
ne 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
Nip to$250.00 a day akainst the violator. Be advised ti.t a copy of this statement may be forwarded to the Office of
tvestigations the DIA for insura . ;overage verif a,on.
do hereby certify un to sins a i penalties o p jury that the information provided above is true and correct.
ignatu ' Date: ta) 31 i aO17
hone#: So'd:X51. 777$ t...-
Official use only. Do not write in this area,to be completed by city,or town official.
City or Town: Permit/License# ---------......-------1
Issuing Authority(circle one): M Ck
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other Q,
Contact Person: Phone#: i
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