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HomeMy WebLinkAboutbldg-17-006102 5Q a\- JIASSACa itJSEr'e i 0 kI .:0 All A,,yCCA i aOV,l �OR A, I ,=t`i)fI'10 y='IERFORN'1 GAS�i aI.Z,o WC°31� ' `.1r CITY L = ' r - e".iit I -- MA DATE , -,?,... _/7 J PERMIT# / Z- 11 i G&&/I JOBSITE ADDRESS .16 -- ....... . ,tpd ,�qy _ ¢'OWNER'S NAME (.2 -of.op_e... .e e,�✓dp_I OWNER ADDRESS ` — ow , o 'TEL FAX ,.„„,._- -_,, X� TEE®R OCCUPANCY TYPE COMMERCIAL:i EDUCATIONAL`, I RESIDENTIAL,I�I PRINT CLEARLY ARI NEW:',,.,. RENOVATION: _._U REPLACEMENT: , { PLANS SUBMITTED: YES....J NO _,.} APPLIANCES 7. FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I,.._..._I` ®11111 ® ®�€ Ail BOOSTERIIIMIIIIOIIIIICIIMIV CONVERSION BURNER i ......... ' _._ ...a�®1111111111111111111 COOK STOVE __ ®� ._._? _.. DIRECT VENT HEATER I111111 J 111111111111111111111 'ME DRYER " IIIMMINIIIIIIIIIIIIIIIIIII FIREPLACE .1111 11. i_ i � .. JIM FRYOLATOR � 1.11 1111111.11111.11011 FURNACE ' i_ rn GENERATOR ... _..._- ` .. . ._ . . GRILLE i _ ®®.._..._.`v.. . i ��.. ,._. INFRARED HEATER , i 111111111M1111111.1111 _._4 _°_ ®R LABORATORY COCKS NIM _. ® ... 01111111 MAKEUP AIR UNIT ® ® . . OVEN .M.-_ ® ® :.. -,I.® ®�:. .,�__..! POOL HEATER # _JINNI' -__--' -- ROOM I SPACE HEATER MINIIIIIIIIIIIIIIIIIIIIIIIII._._ `11111111111MIIIIMMI-- ---' ROOF TOP UNIT _.__... •IMIIIIMIIIIIIIIIIIININIIII F, WI®�® ®tom ., _w1_.• i®M®�. ai .... UNIT HEATER : ��®®1.._.__. ®®® . _...a w UNVENTED ROOM HEATER ® ®®IME I_ I_..._ NIIIIIIIIIINII•---•---t-• ------' WATER HEATER_.... ® ®_ ®�®'_w \ OTHER ..... .. .._... .... ......._ .._.. .. ;:... ._ p ® • m. j{ ��- INSURANCE COVERAGE _.. *N.,f3 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L 1 NO _' I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY �.J OTHER TYPE INDEMNITY __.j BOND I.-_ 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 ___f 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 true and 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 pro ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW ;LICENSE#'12298 SIGNA URE MP.41. MGF _I JP .,J JGF:_j LPGI ,.J CORPORATION .' # 3281C I PARTNERSHIP.. # I LLC ..w#: COMPANY NAME: E F WINSLOW PLUMBING&HEATING I ADDRESS,8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 I TEL•508 394 7778 FAX 508 394 8256 (CELL NIA f EMAIL accountspayable@efwinslow.com _ t if 0 600o's aitgMo�. si,ez,q, Bcureo®d9 MA 02111 Workers' Co rr per'i sation Insurance davit: niiders/Colntrrncton s/Electricians it tubers k._ iicant linformation Please Print Yee .• game(Business/Organization/Individual): e ac.ilkl 1"5113vN Qt%)tm ctl .e.c.bf q. cat) f rit 0 kddress: ' 0,ofauft t rt :ity/State/Zip: Soo Ir't wtcs.A1n MP Phone#: '50S-394-1 17cl ire you an employer?Check the appropriate box: Type of project(required): : I am a employer with "7O 4. ❑ I am a general contractor and I 6. ❑New construction .employees(full and/or part-time).* have hired the sub-contractors ❑ I am a sole proprietor or primer- listed on the attached sheet.8 7• ❑Remodeling 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. El We are a corporation and its 10.0Electrical repairs or additions required.] officers have exercised their .❑ I am a homeowner doing all work . right of exemption per MGL 11.❑Plumbing repairs or additions . myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs • . insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] my 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 aro doing all work and then hire outside contractors must submit a new affidavit indicating such. :oonttactors that check this box must attached an additional sheet showing the name of the sub-contractors:and their workers'comp.policy information. . tint an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site r0Pmciti0n. ('� :+ isurance Company Name: .� rkv � iZJ'U�.6�- i ir--) alloy#or Self-ins.Lic.#: \5 a I A Expiration Date: I-1 an )b Site Address:,. CMMd11 CL1 Ad-1 ONe3Adr, PrI`\ City/State/Zip: O,4!o 7 .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL a.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 f up to$250.00 a day aainst the violator. Be advised t at a copy of this statement may be forwarded to the Office of �� tvestigations the DIA for insurape overage veri ca ion. ( 9 do hereby certifi,un a sins an penalties o pe jury that the Information provided above is true and correct. CC it7natu3 ' A.A. Date: [74 3( i a©t�' hone#: .S)%•3h`1- 7 77 X Official use only. Do not write In this area,to be completed by city,or town official N •City or Town; Permit/License# c \� Issuing Authority(circle one):1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector i� 6.Other. Z Contact Person: Phone#: