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HomeMy WebLinkAboutBLDG-20-001449 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =Fii=y, CITY YtifinO(L*L __._ .. ..._... -- - •G°l U �,y __ ..-, MA DATE g1.11 i�1•••-- 'PERMIT# 6'� 7 JOBSITEADDRESS 1.G.wNDfd.._ i_Sk_A(_ 5py}41.Not e OWNER'S NAME ..Kob(rf P4'L L -___ __: GOWNER ADDRESS .fit Cal/..5+-PirA 1-00.Ai._1-,A.0 31.-).._....TEL30112-2.7_5. 6 ..FAX I-----_--- TXPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL 0 RESIDENTIAL!— .PRI<QiT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:["--- -r PLANS SUBMITTED: YES[] NOE] APPLIANCES 1- FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER L____(�.___-_ ..- _.. I_. y.. .._ 4 . _-41_.---1 L_-J..---.. _ - _ BOOSTER ...._._J_. l-.'1 _11 . .I .. _.. _._._ 1111111E® -_._-• MIN PIK CONVERSION BURNER _- --_ _.._ ._ _ 1 J __ _J __I IIIIMMIM COOK STOVE -- I-.- ,-. i �I -- .. DIRECT VENT ENT HEATER I(.-1 ._,I. I _Ili 1---. .,.-._ _ _. -I-`-. _° DRYER • - • • - - ._ _ �...._- _ ) _I FIREPLACE II-1...__..I �I I. i�lL.,._._ __ FRYOLATOR L. J FURNACE r. =-ZI _.Mr__.4._____L, ,L.,- - ---:MN GENERATOR l �MN -_._. L... .. -.�. GRILLE 1 _.- . .1_ ... ,, ) .. _t i INFRARED HEATER NM I _ _ - I LABORATORY COCKS I . _ ®IMIN® MAKEUP AIR UNIT i_.....,.._ ..1. ..II I .----1L � --: ---.... ._ OVEN MIL _ PM 1 NMI _Awns am iumi on pm MK MIK POOL HEATER '.1111111111111 ROOM!SPACE HEATER ; i- -l- -t OFTOPTJNrr-----------"I — --- � TEST =I ,. 1 . Ma --.. ' -:M lilt— UNIT HEATER _ ' _1� I I`.` _�� - .�. . .I�- � L- ,I ME WATERE ROOM HEATER . . :. _t. -{,_ I.L . .II. ' t. . .i_.�. .. I WATER SEATER .—,- _ OTHER _____ %,_ �I�.t ... ..1 __.J I l l�_ 11 1_ ir ....,,,,,=,...______. . . -_ --- - I_._ ..:I . .._ I-I_ ' ..., INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES PI NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY J BOND ] •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. b - CHECK ONE ONLY: OWNER® AGENT Q . `D 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. rs� S' PLUMBER GASFITTER NAME STEPHEN A.WINSLOW .LICENSE#.12298'. SIGNATURE \..1. MP LI MGF© JP 0 JGF[l LPG'© CORPORATION 0# 8281 C—_ . PARTNERSHIP Q# ,- _ . • : LLC D#., r.._ _ COMPANY NAME: EF WINSLOW PLUMBING&HEATING y-_ .ADDRESS 8 REARDON CIRCLE ' Lie fi- • CITY SOUTH_YARIy1QUTH_ . ... ,. __,_•. ....._,__j STATE _MA ZIP 02664_ . , TEL 508-3947778 . . _ FAX 508-394-8256 1 CELL Nth .. .EMAIL accounispayable@efwinslow.com • • • • . . .4 3 The Commonwealth of Massachusetts Industrial Accidents ? t j= Department of 1 Congress Street, Suite 100 Boston,MA 02114-2017 fA,—''t-� www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH 1'HIJ PERMITTING AUTHORITY. Please Print Legibly \� Applicant Information 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. n New construction (� 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling \- any capacity.[No workers'comp.insurance required.] 9. [�Demolition \ 3.�I am a homeowner doing all work myself.[No workers'comp.insurance required.]I 10 Q Building addition 4•0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will MO Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.Q Othei 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 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: Ilk 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. Ll I do hereby certify and a poi i nd pen Ides of perjury that the information provided above is true and correct a Date: Signature: �° —A../ 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#: