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HomeMy WebLinkAboutBldg-19-006236 iFFL. . , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK it 4_ ,r ` -' f . CITY you-ry,o0-fi, (tt ) MA DATE __. f&b I d- PERMIT#/Qi' D6 -- a e3 JOBSITE ADDRESS _( a_rnt JI, s.ck bc'1v___OWNER'S NAME I o er/f10O,i1M_Q,'. .► ,' GOWNER ADDRESS --_ linoI --- TEL 5Oq�77L-+5jDP'FAX 7_.._... _ . .... . TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL 0 RESIDENTIAL- PRINT CLEARLY NEW:[ RENOVATION:El REPLACEMENT:Ei' PLANS SUBMITTED: YES[] NOD APPLIANCES 1. FLOORS--+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOOSTER I .I NM II I — - - _. —.- .----'i 11111 CONVERSION BURNER list listems opicoutpiminummiont imilMnit COOK STOVE istiON1111111111111111111111111111111111111111111111111111111111EIREEM DIRECT VENT HEATER .____um an,—•F 1 DRYER J 1 - FIREPLACEEmi.ingign FRYOLATOR puma.= � I'® FURNACE _ ® —M1'WL® GENERATOR i-lt-= - MI �® ,ice N• RILLE RARED HEATER ===illarillalliiiII_EL MlNIS - 0 MAKEUP AIR UNIT � � 1111111 OVEN II111111IILII�II1111111111l, POOL HEATER ��i� [�� 0i®�®1'MM,i IN®.�L�isal1®I1M ROOM/SPACE HEATER I®i�®1I ®��11 Ii._1r '®���IF M�M ROOF TOP UNIT .-:�- ; 1 r --11111111 �I� WA UNVENTED ED TERM HEATER ��I� I � OTHER H� 111111 '1l' C I' I 1. �_ '� ! 1J1 L mu i® L_ J INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO (I CNO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW C-- LIABILITY INSURANCE POLICY LI OTHER TYPE INDEMNITY 0 BOND 0 �� 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 ONE ONLY: OWNER 0 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 true a accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compile with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,„Adz.. PLUMBER-GASFITTER NAME_STEPHEN A.WINSLOW _ _ _ LICENSE# 12298 SIGNAT E MP LI MGF 0 JP 0 JGF Q LPGI© CORPORATION 0# 3281C PARTNERSHIP D#I . _ .. .. .I LLC[]#I.. ._ I COMPANY NAME: EF WINSLOW PLUMBING&HEATING _ ADDRESS 8 REARDON CIRCLE CITY SOUTH_YARMOUTH-_ STATE MA ZIP 02664 .. . TEL 508-394-7778 FAX I 508-394-8256 .I CELL N/A EMAIL accountspayable@efwinslow.com .111.2t A•b4 C-,,,ss 6166VI6 IP•46666Y 6 qv 1I.6667,91.646666u466.i Department of Industrial Accidents ; 4i Office f • _;:�1� �r o Investigations .,;I c 600 Washington Street Boston, www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le Id Name(Business/Organization/Individual): E,c.`'dins I ow YL, A.6 1nc 2 .eo.\--(,n c.',,, ,fl lr I Address: cyarn i2a2 City/State/Zip:Sc,1 cr o-,0,4-, t-Or Phone#: -r,_)3- 399-11? Are you an employer?Check the appropriate box: I am a employer with 70 4, I Type of project(required): ❑ I am a general contractor and I '.❑ employees(full and/or part-time).* have hired the sub-contractors 6. ID New construction I am a sole proprietor or partner- listed on the attached sheet.i 7. ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers'comp.insurance. 8. 0 Demolition [No workers' comp.insurance ' 5. ❑ We are a corporation and its 9 ❑Building addition required.] officers have exercised their 10.0Electrical repairs or additions El 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 insurance required.]t employees. 12•❑Roof repairs [No workers' comp.insurance required.] 13.❑Other my applicant that checks bok#1 must also fill out the section below showing their workers'compensation policy information. • Homeowners who submit this affidavit indicating they are doing all 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. tsurance Company Name: ‘.,,.) 0 olicy#or Self-ins.Lic.#: 1$ I yar ' Expiration Date: (-1 — ac1�(> • )b Site Address:D3 mcv)..,,0-0-1,, Cke31_ ,i �� .ttach a copy of the workers'compensation policy declaration page n 1 number and expiration date).P g C g the tp policy 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 Cup to$250.00 a da against the violator. Be advised t at a copy of this statement may be forwarded to the Office of `� tvestigations • the DIA for insuraj•- ,overage veri on. do hereby certify un e e ains kin f penalties o jury that the information provided above is true and correct. is atu? . �� N:�, - Date: (a i 10� hone#: 4. 777g `. Official use only. Do not write i z this area,to be completed by city.or town official. City or Town: ` �. Permit/License# c 4.Issuing Authority(circle one): �. 1.Board of Hea own Clerk 4.Electrical Inspector 5.Plumbing Inspector \� Contact Person: Phone#: