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HomeMy WebLinkAboutBLDG-20-002197 MASSACHUSETTS UNFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -9•+'1- CITY MA DATE ... .._ . PERMIT# G -�� tom` 'mob' OWNER'S NAME um-0�'!C!l_ - . .. . JOBSITE ADDRESS Z^ R e 1. ��� � !G OWNER ADDRESS ._.. ._�!m- _ -- - _ . .__._. - TE Og -?._4 FAX.______-_---L5 TYPE OR OCCUPANCY TYPE COMMERCIAL( EDUCATIONAL[_] RESIDENTIAL PRINT �,/ PLANS SUBMITTED:YES 0 NOO CLEARLY NEW:El RENOVATION:0 REPLACEMENT:L m ' �� �0©©0© 6 © 8 9 101111111153101101 0 APPLIANCES 7 FLOORS WWp� � BOILER *rtkrMMMEWM porno W` L [I J BOOSTER -- ���'���JW CONVERSION BURNER �-�� ���--'��-W� WW�� COOK STOVE «� ��n DIRECT VENT HEATER [W F'WW 1W��W W WOMII ]� MIEW . . . . _ � [� [� • DRYER. . - - �����WWW ��l�l �1� �I I�Wn�®WW, FIREPLACE _ �®lM�liiJl�®I�J�� - r--� FRYOLATOR �� i---1 �� , - GENERATOR ���i�� �n��-I�k RIIMIN I1 GRILLE �®'�«I������-J HEATER illINWWWWW1 WWI W WI IW����: (NFRARED LABORATORY COCKS ��� I � ' MAKEUP AIR UNIT W_M AIR �M W, �-- POON �I ��__ M IWW WW POOL HEATER W ROOM I SPACE HEATER �- �������M���l�iliiiiIMEMetarMi®���� . - ..-- - ROOF-1-pp-UN11` - llilatW�',�'� ili UNIT HEATER - - l ��� �� UNVENTED ROOM HEATER 1�1I�'�®I�I �� I � �' WATER HEATER --. �«'�- - FM �- ® ��-���- OTHER I��® i®I®� wWW. _ _ __._ 'MIM MW ®M M on I Lam' -"'"'""' ® INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES '0�. NO [l I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW BOND LIABILITY INSURANCE POLICY 0OTHER TYPE INDEMNITY 0 •OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1Of; Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER[ AGENT{-.... SIGNATURE OF OWNER OR AGENT curate to the best of my r r I hereby all certify that w°work andetails installa tinformation I have ns performed under the(tted or permit issued for hisding this applicationplication will be nare true compliancd ith all Pertinent provision of the and that all plumbing•Massachusetts State Plumbing Code and Chapter 142 of the General Laws. . `pSIG U N' PLUMBER GASFITTER NAMESTEPHEN A.WINSLOW __ ,_ • _.LICENSE# 12298 . —-� _ LLC D# �J MP MGF[� JP© JGF Q LPG(© CORPORATION 0# 3281C.__ - PARTNERSHIP L�# COMPANY NAMEtEF WINSLOW PLUMBING&HEATING !ADDRESS 8 REARDON CIRCLE CITY I SOUTH YARMOUTH, . .. ,- .a._...__..--....-----•1 MA STATE - 'ZIP 02664._ TEL 308 394-7778 ::. __,,,,.__.. . FAX 508-394-8256 CELLI NIA , . .• lEMAIL accountspayable@efwinslow.com • • 5 �� The Commonwealth of Massachusetts ? = G Department of Industrial Accidents =_V= 1 Congress Street,Suite 100 s -"���- Boston,MA 02114-2017 n r„='�� 'ter www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly \ \ Name (Business/Organization/Individual):E.F. WINSLOW PLUMBING& HEATING CO., INC Address:8 REARDON CIRCLE \ ,o City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 J 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. El New construction 2.1=1 I am a sole proprietor or partnership and have no employees working for me in any..opacity.[No workers'comp.insurance required.] -- 8. Remodeling 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. CIDemolition t A 4.0 I am a homeowner and will be hiring contractors to conduct all work on my ro ertY I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.ElElectrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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 01/01/2020 Expiration Date: 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 !ties of perjury that the information provided above is true and correct. Signature: r 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#: