HomeMy WebLinkAboutBLDG-19-006158 . ',____. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY _Ung-)1404/r-H- cioc,(2 0 MA DATEI IPERMIT# di-46-71?-ad 7 ;
JOBSITE ADDRESS LC) 14014 ttbtZl .- (2‘),/÷,0 OWNER'S NAME 1_e,Si4- Pe 2 -t---)/t-) I.
GOWNER ADDRESS I gi..9/1///24-e 5 t/11-" ,..5/.21{,_31-(a__Tier? TEL6d k-I-j0c)•Zo7-4-.'..):.3,FAX., , _
TYPE OR
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OCCUPANCY TYPE COMMERCIALE] RESIDENTIALEV-
PRINT
CLEARLY NEW:Er RENOVATION:0 REPLACEMENT:I:1 PLANS SUBMITTED: YESEI NOD
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 I 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE ,
DIRECT VENT HEATER . _ __
DRYER
FIREPLACE s, 7 , ...,
FRYOLATOR k , A - .
FURNACE 1 g
GENERATOR I ,
GRILLE
L
INFRARED HEATER ,, - . _ .
LABORATORY COCKS N6.
-
MAKEUP AIR UNIT
OVEN 4..,
POOL HEATER
ROOM/SPACE HEATER N
r _
ROOF TOP UNIT /
TEST i /
UNIT HEATER /
UNVENTED ROOM HEATER 1 , __ \
WATER HEATER - ' „.. 4 a
OTHER I .../ 1
,
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of M .Ch.142 YES 0 NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
In-
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY El BOND n
,
OWNER'S INSURANCE WAIVER/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 ID
kV SIGNATURE OF OWNER OR AGENT
N I hereby certify that all of the details and information I have submitted or entered regarding this application are true a accurate to the best of my knowledge
"3.... and that all plumbing work and installations performed under the permit issued for this application will be in complia e with all Pertinent provision of the
•t\ Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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.--. ... PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE
MP El MGF El JP I=1 JGF[-.1 LPGI E] CORPORATION I:1# 3281C 1 PARTNERSHIP IE:I# LLC 0#
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
m- CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com
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Department of Industrial Accidents
_ l Office of Investigations
_'sEl�1i= 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ` Please Print Legibly
Name(Business/Organization/Individual): E‘C•Vv+"510i,v 01/4),•,•.t: wu^' . ce t� ce• 111(
Address: 7' (4t �=�tQ- (�
City/State/Zip: Sc.s kveN f cry ,c,.,k NP Phone#: '503- 394 r 1 T1
Are you an employer?Check the appropriate box: Type of project(required):
XI am a employer with 70 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or paid=�me)* - - have hired the sub-contractors 7. Remodeling
El I am a sole proprietor or partner- listed on the attached sheet.t ❑
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
officers have exercised their 10.0 Electrical repairs or additions
required.] repairs or additions
❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing
myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13.111 Other
comp.insurance required.]
thy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation.
isurance Company Name: A+( •t� ,3 ( J O •Lnsc Ace_ ` a), fly
olicy#or Self-ins.Lic.#: 1$a) Pr
i Expiration Date: —1 — ao
)1)Site Address:,3 CzYvvv C'�1 w'�'0 - C�5 ,rn 11 City/State/Zip: OY- (a 7
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
Cup to$250.00 a da a ainst the violator. Be advised t at a copy of this statement may be forwarded to the Office of
ivestigations the DIA for insura overage verif a on.
do hereby certify un a ains a penalties o p jury that the information provided above is true and correct.
ignatitr : Date: [D13 i aoi
hone#: .S it.-.354. 7 77g
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#: