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HomeMy WebLinkAboutBLDG-20-002196 a\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -v ._- CY _ ' .T,r . . - MA DATE PERMIT#���°/0 �, JOBSITE ADDRESS OWNER'S NAME UriffriFfiriM IIM G OWNER ADDRESS l( _____ _ - --- - .TE 114 _l g_r##.1 . - FAX . --- - TXPE OR EDUCATIONAL -__ RESIDENTIAL Tr, OCCUPANCY TYPE COMMERCIAL � PLANS SUBMITTED: YES[] NOD CLEARLY NEW:Q RENOVATION:0 REPLACEMENT:Ig------ n 6 la 8 g BOILER I��' W� APPLIANCES�- FLOORS-3 ®0 BOOSTER ��LWWW WWIVISTOI � CONVERSION BURNER «MM — .,.. COOK STOVE � � LMJ WWWW' ��'�'I DIRECT VENT HEATER �- *10111 • DRYER. J>� I � WW FIREPLACE IM TWO' FRYOLATOR - 1 Wes FTLIMM � FURNACE �� � �I��� K>�! GENERATOR 111�I , 1I ��I--I GRILLE KWIrrig INFRARED LABORATORY COCKS IomI���W out WoL WW mil'1� IW-�WW',�'�-'1 MAKEUP AIR UNIT WL __ Jr� OVEN � '���I���� - i' Wes' �'- POOLHEATER ����I I �J��— WR ROOM I SPACE HEATER -- --------`M CB11=�C�_ =WIN EN®find PW--- --- RODrrOPt1N►fi 11I UNIT HEATER illL � � Lam' WlCM -- -- UNVENTED ROOM HEATER 1L®1L�® �W �] _____ q WATER HEATER ® W� MWMj�'�® W�-- OTHER _talo �®� ® LW i 1 M®IMM. .-IM®® 0WIMIE.11® INSURANCE COVERAGE I have a current Habilit insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ONO _ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW BOND n ! LIABILITY INSURANCE POLICY[:� OTHER TYPE INDEMNITYL� •OWNER'S INSURANCE WAIVER: that ar siphat the nature licensee on this permit application waives this requirement. by Chapter 142 of the Massachusetts General Laws,andmy 9AGENT 0CHECK ONE ONLY: OWNER El SIGNATURE OF OWNER OR AGENT I hereby all u gll of and installationsi performed under the submitted permit issued for thiss application ng this will be ncation acomp'' ce with all Pertinent provision of the and that all plumbing workI, •Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��`� —`�,'. �, S' PLUMBER GASFITTER NAME STEPHEN A.WINSLOW_ i LICENSE# '12298 S 6' GF JP[� JGFC LPGI© CORPORATION[# 3281C PARTNERSHIPL # LLC ]# mr fr) MP 0 M __ w VI COMPANY NAME: EF WINSLOW PLUMBING&HEATING.-,._�ADDRESS 8 REARDON CIRCLE STATE MA ZIP 92664. .TEL 508:394-7 7-8 - : _ -:_ •_ :__ . CITY SOUTH YARMOUTH ------� . FAX 508-394 NIA8256 CELL EMAIL accountspayable@efwinslow.com - - . • . ai. . tC 3 The Commonwealth of Massachusetts _; t G Department oflndustriadAccidents _i�1e�� 1 Congress Street, Suite 100 o=''� f Boston,MA 02114-2017 www mass.gov/dia \Yorkers'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 V � City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 NAre you an employer?Check the appropriate box: 1.❑✓ I am a employer with 88 employees(full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in Type of project(required): 7. 0 New construction any capacity,[No worker„',mp,insurance required.] 8. 0 Remodeling 3.�I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9• ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on myproperty.er I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.Q Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.0Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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.Lie.#:1909A 01/01/2020 ro Expiration Date: \ Job Site Address: City/State/Zip: 1\ 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 imprtsonmenc as well as civil penalties-in the form of a STOP WORK ORDER and a fine of up to$250.00 a �v\ 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 lties of perjury that the information provided above is true and correct Signature: ��.. ii-°., �` -. Date. Phone#:508-394-7778 1 — Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# `-J 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#: