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HomeMy WebLinkAboutBldg-20-002193 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK age - _,�f 4 CITY I Y Mad� _ MA DATE--Jd1Q•,/1 . 1PERMIT#___ _— j ._ JOBSITEADDRESSI-1Q...5lA.fo.GJ(14_-5f.yA ok ._IOWNER'SNAMELA f ttl ile- --- `` 4 3 �$4FAx � OWNER ADDRESS ` rjq/_�!�� -- - - - _- - __�TEL TYPE OR OCCUPANCY TYPE COMMERCIAL[] �EDUC/ATIONAL[] RESIDENTIALPRINT CLEARLY NEW:Q RENOVATION:© REPLACEMENT:Lam' PLANS SUBMITTED: YESL.. NOD APPLIANCES 1- FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 112 I 13 14 BOILER I _ MOMMAj � CONVERSION BURNER I -_ I i "®l BOOSTER M = L- COOK STOVE min - IGOMIismDIRECT VENT HEATER OIWINWINI - - . . . . - - 1 Mi .- I. I : ...� R DRYER �I I•.•.-II. . ....JI 11.-.-. L._• FIREPLACE IM u ��MI FRYOLATOR - �� FURNACE -1-_-...._.: ..._. _ .._ .. _. GENERATOR liMilin I____'MINIM MN'MN GRILLE MIK _ MINIM INFRARED HEATER Tall 4 al ® M IM 111111MWMIT.MN LABORATORY COCKS ����I��-� � �,. .__; MAKEUP AIR UNIT �11�I=I.. ...•,I • - ®� _OVEN MI_.. 1L.. . .. _. .I - . I-- . I;... � �M POOL HEATER . _ I 1..... . ....... . I__ --I.... .1� i OM_I. _l ROOM I SPACE HEATER I - 1 • _.__,1 — � 1 _ TESTOPUNi` - - - !� UNIT HEATER m»1M I UNVENTED ROOM HEATER I� ® -J- WATER HEATER M��� M�1 M�� - - _i OTHER MI-. ...IL-.-.1... ...:_ ..._._.i._.... . ®_M. '-... :1 ___MINI .... . N . . I .. . IL_-1. ..I W_®WI — 'I��_ • -_. _�. : I..._.— _I!alhI_......_,II......_I...__I-� �- . il ......_.._-----.... ----- INSURANCE COVERAGE l have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1-...q NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LI OTHER TYPE INDEMNITY 0 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. CHECK ONE ONLY: OWNER Q AGENT 0imPT 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 an ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian with all Pertinent provision of the •Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (- S. PLUMBER GASFITTER NAME STEPHEN A.WINSLOW LICENSE#.12298 SIGNATUR MP 0 MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION D#18281 C_- . I PARTNERSHIP D# LLC[il# M COMPANY NAMEaEF WINSLOW PLUMBING&HEATING--. ADDRESS 8 REARDON CIRCLE = CITY ISO.UTHYOMOUTH . ... .. ___..__s.._._._.____..I STATE _MA_'ZIP'Q2884.- _.._1TEL 508:394 7778 __ . FAX 508-3948256 CELL NIA . .... EMAIL accounfspayable@efwinslowcom - a4- 5 j VY T The Commonwealth of Massachusetts Department of Industrial Accidents ;::?i�1tw 1 Congress Street,Suite 100 LE= Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers. TO BE FILED WITH nit PERMITTING AUTHORITY. Applicant Information Please Print Legibly C) Name(Business/Organization/Individual):E.F. WINSLOW PLUMBING&HEATING CO., INC G 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).* 2nr -, , •'�P or partnership-andhave no employees working for me in- — $. aRemodellrig any capacity.[No workers'comp.insurance required.] - 7. El New construction 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on myproperty.er I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or aresole MD Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑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.: 13.El Roof repairs 6.0 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 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 e palL nd pen Ities of perjury that the information provided above is true and correct. • Signature: ? ���ti-- 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#: