HomeMy WebLinkAboutBLDG-20-001714 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
.7 71.721 a 1•.= CITY YARMOUTH MA DATE 09/25/2019 PERMIT# 4�17I /
JOBSITE ADDRESS 168 MAIN STREET CQ OWNER'S NAME INN AT YARMOUTHPORT
G YARMOUTHPORT 7 CHARLES DAY
OWNER ADDRESS TEL 81-308-5549 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL El RESIDENTIAL El
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: ® PLANS SUBMITTED: YES❑ NO 21
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER 1
FIREPLACE
FRYOLATOR
FURNACE --
GENERATOR YIP
GRILLE
INFRARED HEATER \J
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Ri NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY g OTHER TYPE INDEMNITY El BOND El
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 ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are t -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 com•i. 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# 1229; SIGNATURE
MP g MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION[I# 3281C PARTNERSHIP❑# LLC❑#
COMPANY NAME EF WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com
WORK ORDER 512750$50.00 / /�� GO !i'�y
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The:Common ?ealth of Massachusetts
s t. DeP t o, ndus>5 Atrc dijbrsts
I.; Congress• 'reo Suitt 1.40
w i Boston,MA 02114-2017 .,
`1 gam,.*` 44.00v gov1rti'a
T ork e s'Compensation Insurance Affidavit;Builders/Coat ctor leetricians/Pittaibe>rs..
TO`13E FILED WITH-THE nitmt rilid AUTHORITY.
ti Vl tai ttltleln Please:L tat lhly'
14. +e " o . .':;_... ' f.WINSLOW PL MBING-&HEATING O..:.INC,
As>t; � 1`CIROLI
a �EARMOUTM,MA.02664 Phone#:508-3944.178
• Areyqu an emplo C_,51 appropriate.:box:
Type f pro3cet(required)s.
1. a emp'li with' employees(full'snd/or part=tiiae).* 7- 0 New coistrudtiba
!1 - ' 2 tAm:ai:91*- :have eaiployies'workitg Forme la: $ titentiiklint
�Y .4ti~w.ode comp.insurance requites�' 9 [�:DetxutlitliiQn
Sm►a t}dliyeowitet'doing.all ork 1ayself[No workerlt'camp.insurancere quired)?
a= ,1!AP4 .hcaniownerattd will be egacontreotors to conduct all work on m .YR 10 ;Build; g dition
+ Lwhl
ensureI Cr or eit 'aveworkers'.compensation insuranceorare:atile' •11:ll'$ rival rt +orta lions
prop l wint no eempleyees.
12,0 Plumbing repairs or-e itions
5 '•l' 2 i rotilrartorand I h it t the sub contactor It ion the attached sheet
Tlteso atil Smt tma haveemployees and have`wockax' '. t 13 :_1%1of repairs•
tromp+msurdnFe.
6 ' earl ttda � *xeiviiod•theirrightole empao.n;per-MOLe. 14 DQthtsF: ::., ., :
t52,I1(4)a�4 no,d 1 INo w ke s camp;in�tequired.]o)rees.
illout rn ton below showin theirwrorke cotr lion poliy riil
f '.` sir,_ rating they ate doing allewo k ettt then hi a outside conttactorc miust saibmit a ne w aiOteteit'indt"cating such.
,hat+d�tu F �dl�nn,additional shcciShowin,g`t a name ofttiessub'oont actors-and state whetherar not those entitles.have
l iu, o oy they"it 'l ' 14 comp.p number:
I ttottilt Eitiokoriitatil4pr4401g7vtiikerhe compensation tnsurance/ormy foyeee BelowIthe palky>arulft¢slte.
infor ationr.
Ce y`N ` ; Q IV ti+IUTUAL.IN.S.URANOE:COMPAINIY
Policy.#or-Self ins.Lic #,1:909A z_EiiiiirationDatet01'10112020
Job:o'ite AktOteoi , - City/State/Zip ,. ,.:,
' Attach a copyofthe'vit► er?"compensation policy.declaration page(shoningthepolicy•number a"nd expira ti.tlate).
s r*tovek -as required'l rider MGL 0;:15 , A is a criminal violation':punishablee 1 a fineufYto , .00
and/or oncicar ampri onment,as well as civil penalties.in the form of;a STO WORK ORDER;anita fine t fup`to$2SQ:00 a
day ag�stcthe violator A cc y of this statement,may be Averded to` Office:of lnvestigations:of'the A'for inure
. a .w .op,
do .ces ,', ,, '. i'lp- as 1".j ii0ihatthre�Info ml pn.0proi da ii Is trueandorr
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Si a i,:23„a:±` . . ,,. • Dow- . .-. .
- P.ho a 8494 8
Oitlifiiilatt Only. Do not tvt In this'area,to be completed by et*'Or WOO Offieta
City or'TTown Permit/License
g Auh0110qtit ne):
I .Bd:�of oarl_ealtb Z.BuildingDepiutoeitt 3...Cty/TownCietk et.Elec al:Inspector f "Plumbin a jector
6.Othher
C 'tict Person(: .,Phone# : --