The URL can be used to link to this page

Home My WebLink AboutBLDG-20-001500 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YGf/YI461-1/3. - .. .. ..._...- - ••..-_= MA DATE,_111� /'�...._ PERMIT#0496 'SO-6 JOBSITE ADDRESS IS..Oic 1,1 L.i .Ve5J-.Ytri.twilik. OWNER'S NAME,,(h,,r`5 nJ/Q._.______.-___._ OWNER ADDRESS - (PO ._5/14}14 .?I.u/mD.tlaQz�(Z. TEL S_Qg 94f 3TYPE OR 5S ..F��------------.. OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL 0 RESIDENTIALB CLEARLYPRINT NEW:[ RENOVATION:[] REPLACEMENT:[ PLANS SUBMITTED: YESO NOD F " ' OOR 2 3 4 6 6 7 8 9 10 11 12 13 14 BOILER II... .�.. .. . ..i - 1 --...TI T - - ._ BOOSTER cmm• �► -- - _ I -main mmilmiliimm---...mitmirminimmimmmuj DIRECT VENT HEATER _F-mww-isupwridm-swimmmitunimmuutpummi FIREPLACE . _ IM[*. - ! FRYOLATOR �l)...._._�_..__..,_F.__I_I...__ .. � .. _..� .... ._.1I-�I:��,..1 GRILLE _ INFRARED HEATER I-_.._ ._I_- -1- --. I —� — -MMAKEUP AIR UNIT it � MUM_ �� I 'Er� �� I I i ROOM/SPACE HEATER TEST � �, _ i lid:��ME��!!E MEWS �,�_._�I UNIT HEATER' _ UNVENTED ROOM HEATERV I �.— - WATER HEATER NNWI .. -- MIME ��I � f�® I ..1 M1111111M.MI . .._I_..._,1 _ _1... ..._ ....__. .. _ .L . . __._._ .. __II __ 'CD INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY a' OTHER TYPE INDEMNITY d BOND 1 •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. c!� p (-4 CHECK ONE ONLY: OWNER ID AGENT Q - 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 accurate to the best of my knowledge T and that all plumbing work and installations performed under the permit Issued for this application will be In comp) e 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. SIGN URE MP O MGF JP 0 JGF[,] LPG!O CORPORATION 0# 3281C__- _ PARTNERSHIPS# ,- _ . , LLC Q#�. r-.._ .. COMPANY NAME:I EF WINSLOW PLUMBING&HEATING _ 1 ADDRESS 8 REARDON CIRCLE CITY SOUTHYARI4OUTH . , __. STATELMA,..ZIP 02664_ , JTEL_508-394-7778. FAX 1508-394-8250 1 CELL NIA •EMAIL ac counfspayableeefwlnsiow.com tiV UQ t;v . a The Commonwealth of Massachusetts *= Department ofIndustrial Accidents I - p �4 �-j='q. 1 Congress Street,Suite 100 �,_1`(_�� 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): LID I am a employer with 88 employees(full and/or part-time).* 7. D 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 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10[]Building addition 4.0I 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 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.❑Other 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§I(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: N. 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 par s nd pen !ties of perjury that the information provided above is true and correct '�`� "4 �..®d�- Date: t!'' Signature: �° � ( "f 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#: