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HomeMy WebLinkAboutBldg-20-001640 aN, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK —''"'= � MA DATE /g//4-_ 1 PERMIT# D�? ,G{_ r CITY ____... .. ...-------._.__ .._ JOBSITE ADDRESS1RA.,WQo.0-Rd _5Riti-h..Worpok,.OWNERS NAME ./ePp 9_,Li_ A/a !. . GOWNER ADDRESS .,__ ___._._________._ -__-_____--.- -=TELL If. 3 4. .FAX� TYPE OR OCCUPANCY TYPE COMMERCIAL_. EDUCATIONAL[] RESIDENTIAL[__; PRINT CLEARLY NEW:Q RENOVATION:® REPLACEMENT:1 PLANS SUBMITTED: YES0 NOD APPLIANCES I- FLOORS-+ BSM 1 2 1 3 4 5 1 -6 .11 7 8 9 10 1 11 12 13 1:_-4. BOILER NM - _I-- 1-_r. -- . - ._. - , BOOSTER Wig LMIlMhr l OIMI 111111.1111111.1 ------ PO CONVERSION BURNER MD I__ --II . . ..I MIMI�— MI.W `- r-"i hh h h COOK STOVE Ihi �h _- h h1 DIRECT VENT HEATER __ MIMI ----I h - SKIN DRYER - • • • ----_.. - �� FMM FIREPLACE 1 « anI � M MI�J(I . FRYOLATOR �� ! ` r FURNACE GENERATOR 1hIhlhlhl Jhhh'��M h Al rnai• �� �#�[ht��h,h������. GRILLE hMhlh r h _ 1�= I —I INFRARED HEATER M� 1-- -J --- I_ - - - hN LABORATORY COCKS 1 _ ® r -.. I __ .117 . I'iin NM -JMEMM'MAKEUP AIR UNIT rig I -I _ �OVEN lt . I 'W W1 POOL ail 1_, ROOM I SPACE HEATER �h hEMhh�h®r -h� -J - I M----3 Oar--- --- TEST I I .=i .: _ _ ..-; : _,��` ', UNIT HEATER Lh��—�� �®�, UNVENTED ROOM HEATER L._y,� I L IIIMI WATER HEATER . _ iii 1�II OTHER h��---:_�=`' WW1 'I _'Ih r� h® I . . 11111111 L._ _..__ ._. .. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1/71 NO [l I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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[:3 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 d 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 compl a with all Pertinent provision of the •Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME STEPHEN A.WINSLOW . LICENSE# 12298 G TURE� � C� MP El MGF 0 JP© JGF Q LPG.0 CORPORATION 0#13281C - I PARTNERSHIPD#1 - • . 1 LLC D#l_ .-..._ _. .I c COMPANY NAME: EF WINSLOW PLUMBING&HEATING .ADDRESS l 8 REARDON CIRCLE CITY SOUTH YARMOUTH .w_. ___w._.u,_ STATE I MA 1ZIP I 02664.- 1TEL M 508 394-T1T8 _ _- FAXI 508-394-8256 I CELL NIA . EMAIL.accountapayable@efwinslow com a The Commonwealth of Massachusetts Department of Industrial Accidents �tllil:i 1 Congress Street,Suite 100 _ {= Boston,MA 02114-2017 \r www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH 1'Hh,PERMITTING AUTHORITY. Applicant Information Please Print Legibly �, 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 88 employees(full and/or part-time).* 7. ❑New construction 2.0I am a sole proprietor or partnershipand have no employees for me in v • , p p working 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doingall work myself. t 9. ❑Demolition y [No workers'comp.insurance required.] 10❑ Building addition 4. 4.0 I amensure a homeownerthatallcontractors and will btithe hiring contractorsworkers' to conduct all work on my property. I will eer compensation insurance or are sole 11.❑Electrical repairs or additions dproprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 ROOF repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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.Lic.#:1909A Expiration Date:01/01/2020 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 MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and a pai s nd pen lties ofperjury that the information provided above is true and correct. Signature: r ' ----.....4._ Date: Phone#:508-394-7778 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#: