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HomeMy WebLinkAboutBLDG-20-001601 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -= ' ''' CITY 11,4 511` y./ 21n Af..<t_TA- _- MA DATEI_?_/_Y-I F._ .1 PERMIT# JOBSITEADDRESS `J'.OZ4'IV.__47./L ._OWNER'S NAME 1 ( 4/f .. Co Il-C•_/✓____..._. (y OWNER ADDRESS I.... ,___._.__✓.(... _L ..-._.._...____________. __ITEO:8 _ZTBy/_S.d.'IFAXIy _..__.___ 1 TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL Q RESIDENTIAL fg PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:( PLANS SUBMITTED: YES[] NOD APPLIANCES 1- FLOORS--I 8SM 1 2 1 3 4 5 1 6 1 7 8 9 10 1 11 12 13 14 BOILER ����� . .. F_ ��� —���1II�I� --- a �I� CONVERSION11 ONSTER COOK STOVE I�L��������W����� M MINIII11®lM l ICI ® BURNER Mum wil. DIRECT VENT HEATER m _ r� merm DRYE • •R FIREPLACE L 'L�� Jim i_- -- ... .. . � FRYOLATOR I11111 � I I 1.1 EMI 11111 FURNACE I-- - ilii I_ __,I .I GENERATOR. _ - ..-.....J ...._..�.-,_-.I--_.- i .. .,. .._ ' GRILLE •-I int NFRARED HEATER � ',�--.-�� ---" I�l � �-" am LABORATORYAIRUNIT M. 'M I��MI MAKEUPL giz . I j il Wag OM SON' OVEN � , �:�'l iM, POOL HEATER111.101._...._ �--''�� '� _i__�Uir_�_1�_1_i_1 li ROOM I SPACE HEATER - _ I I i J���- -R6OFTOP-tl"Nlfi---------------ow i - TEST - r :. ' r \ UNIT HEATER - l I I • J ,......, UNVENTED ROOM HEATER ��, .. --- �Iw WWW111 [i ® US1 I I MEM WATER EATER _ _ -�— ��� OTHER I I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ril NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY .+; OTHER TYPE INDEMNITY E 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 El 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-nd 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 comps I ce with ail Pertinent provision of the ;Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r.. /°' i • uaA.f -ice' PLUMBER GASFITTER NAME STEPHEN A.ININSLOVV • . _ .,_, ,.LICENSE#_12298..,. SIGNATURE MP0 MGF© JP© JGF0 LPGI© CORPORATION# 3281C-- , PARTNERSHIP OM I _ - _ 1LLC0#1,. _..._ _. 1 COMPANY NAME:I EFWINSLOW PLUMBING&HEATING.. . ,IADDRESSI 8 REARDON CIRCLE .. .- CITY SOUTHYARMOUTH . ..._,. _s____ STATE MA ZIP 02664- TELI508394-Tl78 , - ., _.-.1 • FAXI508-3948256 I CELL NIA . ., EMAIL accountspayable@efwinslowcom .._� . The Commonwealth of Massachusetts c, I 1 t_, _ ! Department of Industrial Accidents _::014= 1 Congress Street,Suite 100 _ �= Boston,MA 02114-2017 \ www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. O 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 \_) City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 i , 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. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8 ^Remodeling any capacity.[No workers'uunip.insurance required.] t_t 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]1. 9• ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on m Yproperty. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors 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. These sub-contractors have employees and have workers'comp.insurance.t 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. 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.#: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 epai s ndpen Ities of perjury that the information provided above is true and correct. 0 Signature: l° -•.o d 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#: