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HomeMy WebLinkAboutBLDG-20-001883 • . 0 J- on11...dam / i ' 0'/H_PlT.-Row/ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =L'- MAD 1 ERMIT �_G= � CITY� _ - ATE_...,___._..... .. JOBSITE ADDRESS' _ .._ .:_._. -. .__ .._ ...,........ _ . ._(OWNER'S NAME _- __ ______-__._.._. G OWNER ADDRESS I_.. ._____________._ .._..__ -_- ----i TELL - . iFAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL D RESIDENTIALD PRINT CLEARLY NEW:0 RENOVATION:G] REPLACEMENT:0 PLANS SUBMITTED: YESO NO0 APPLIANCES 1 FLOORS--I M0 2 3 4 5 6 7 8 9 10 11 12 I 13 m BOILER Imo' ilil �I CONVERSION BURNER WEN 'M11.0h—iiiiii , WI COOK STOVE Il__Uh.Mid ®J ; FRYOLATOR DIRECT VENT HEATER laillMINIUMMINIIIIIIMAIII11.11-111111COLWRIONAI Cam.. . . I� ► I_- II -- _- (.. .-1= GENERATOR Il f C � - ..-. .... — GRILLE MEM INFRARED HEATER 1111111131122rrngi —iiMMIIM.M1 :AID— OVEN . ,HEATER -rW_CM.. ilk' 'il a �I IIl1�' ROOM I SPACE HEATER 1111111•1111111111.11111.111111MAIMBIllinnilitia_Wow •• . ®®'®llMhl�en WIIIIM[ MPA- R�oFi'oP-r�Nrr----------------- .� �I��l�W—�-J TEST l «[ li UNVENTED ROOM HEATER II- � 1 ����®WI � M UNIT HEATER �� �� �1 WATER HEATER _. I 'CM' M '��' �r���- M'MI [ ini OTHER MM�WW ®M�1m1mmi-MMI __ . .... . . ''MLA[�®IMMI®® 1®M NM —A_,MM__ -AIM ®I. 1 ®®® Iim®I ® — ` INSURANCE COVERAGE i have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ill NO 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 ID AGENT i0I . SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru 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 comp ce 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 MP 0 MGF[l JP 0 JGF Q LPG10 CORPORATION 0#`8281C-__ . (PARTNERSHIP[#I } ,. . _ 1 LLC Q#an COMPANY NAME:(EF WINSLOW PLUMBING&HEATING__ -. .ADDRESS(8 REARpQN CIRCLE . ..- --... .1 CITY SOUTHYARMOUTH. - .-. _...,_..__.____: STATE -N1A 4IPIQ2884 ITEL(508-394-7778. , - 508 3948256 I CELL NIA . ,.. _.. EMAIL accountspayable@efwinsiow.com . .. . . - • liU 3 The Commonwealth of Massachusetts Department of Industrial Accidents _1tllil:- 1 Congress Street, Suite 100 7,72E_ <' Boston, MA 02114-2017 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 City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 88 employees(full and/or part-time).* 7. ❑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'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 ❑Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑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. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 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 t 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 e pai s nd pen [ties of perjury that the information provided above is true and correct Signature: -°-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#: