HomeMy WebLinkAboutBLDG-20-002421 .C , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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INSURANCE COVERAGE
b<-3 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ONO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
�' LIABILITY INSURANCE POLICY .�' OTHER TYPE INDEMNITY[l 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 0 AGENT 0
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 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 th e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 14[4 �� •i
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW ..-. _ _ , LICENSE# 12298. SIGN URE
MP 0 MGF 0 JP 0 JGF Q LPGI Q CORPORATION 0#(3281C__- _ I PARTNERSHIP OM _. _ . _ 1 LLC D# -.,-.. -. .I
COMPANY NAME: EFWINSLOW PLUMBING&HEATING. .ADDRESS)8 REARDON CIRCLE •1
CITY SOUTH YARMOUTH . ... ,. _:___ _.._,_ __ STATE STATE l MA 1 ZIP 02664. TEL 508 394-7778 - : ... _,_ -�_
FAXI 508-394-8256 I CELL NIA . .. EMAIL accountspayable@efwinslow.com
. • . 68- -- - '3 /�
_ The Commonwealth of Massachusetts
11 _ 1, Department of Industrial Accidents
-5 t 1 1 Congress Street,Suite 100
---� ;_ tl-_ Boston,MA 02114-2017
r = www mass.gov/dia
^� Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lesibly
Name (Business/Organization/Individual):E.F. WINSLOW PLUMBING & HEATING CO., INC
N. N Address:8 REARDON CIRCLE
,, SOUTH YARMOUTH, MA 02664 508-394-7778
t. City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
l.Q✓ 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 forme in._ S. ❑ Remodelingany capacity.[No workers'comp.insurance required.] -
9. 0 Demolition
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
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. 13.0Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑We area 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.
tContractors 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
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 pai s nd pen Ities of perjury that the information provided above is true and correct.
Signature: ' . .zv_ 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#: