HomeMy WebLinkAboutBLDG-20-002722 OFFICE MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
YARMOUTH
.,_ 4,T CITY MA DATE 11/07/9019 PERMIT#/3 "a4 vd 7014
JOBSITE ADDRESS 60 BROADWAY UNIT: OFFICE OWNER'S NAME ENGLEWOOD CONDOS
GOWNER ADDRESS WEST YARMOUTH TEL 781.258.7564 FAX
TYPE OR MICHELLE COLLINS
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL_[
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NV
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
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
•
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER GAS TEST 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [V7 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY g OTHER TYPE INDEMNITY ❑ 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 ❑ 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 . ‘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 compli.J e with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
4/0 , ,.e ( t..j
PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE# 12298t SIGNATURE
MP g MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION 0# 3281 C 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 515238$50.00
The Commonwealth of Massachusetts
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' 1 :y 1 Congress- e4 Sum 100
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.Boston,MA 02114:2017 •
www-marss.gvv%dia
Wintk0Of Compensation Insurance Arndavit;Btiihders/Cont'actors/Electi cjanslplurabers.;
TQ.I.I1LE WXTH.TiMmi I Tn AI)TH(RITY:
.ppll'onttiifo`emation: rt,... Please;Print eslbly
Nine il,4*la/ pe % tdi.'r eibal) E.F:W SL W'0.L MBtNG&HEATING Co .ING .
"Address;;8"R)rA1 IX)N BIRO E-
-S :SOUTH ' M.Q.UTH.,MA,.,92664 , -:Phone#y 50.8=894=7778
Are-ynu an eaiplo t' eClt the appropriam box: e o ec r
o.c� TYP p C etX i*Ot
} nm a;employer With a mplayees(full andlor part-time).
7. .[INew construction
?:Q I.am asgle_prop intot pa:tnship and.havc no ediploycesvviorking forme in $. Reriiodeling;
anyrmpadity:Pkworlceas-"comp innutance required]
d;Dt.am a1}omequmer.doin&ali wemle i njarlf,[iVawoticers'cgip.insurance t I �]'Demoiitiern
1 f10 Bwttl'ding:-addn~
4- " X•am a hpndeownerand b 0 a lilting eontrantors to conduetell riroric ink my propoty. Twin
ensure-thatai Oti trataor5crtborhaveworkes'compensatniiinounsncc raresole l I frl lca1 rep rs,re attdfiibins
jsropnetot>p<wrHr nu employees • • 1.2 Plumhin is or addt o}is
S.Q l am age9 er t cotnrsi for and 1 hiivedtlred,the su&-coitfractorrlisted on the attached Shect 13: l esei f rt ait5
The e-sub?4onaactori have nptoy and have workers'comp,ttreutaacc..f
6 -= sre*dotpbraurkaid oF�Cca�a3aveeXarctseai:tF��ltt.oP-mtemption-pec`1b[GI:a
14 D0thar-
I5ZIl(�11,s ondave haveno..ttplo oes.[1Jo workers'comp;tnsvtanpd ttquired:)
°•An.Y46. ant''t iih vbpx*l m*tilin tt put,tNI onbelawshowingfthch-wadcets noitpolicyrttfornu�iilin. -
t it .n conwlut iiizibrntctb a idavnlndreattng;fhey are:doing ni:work and:then hire o ttsrde fifflietara must submit asnew affidavit mdicnttng such,
;C ots tint check tins box must att red enad itti�onal�shc`ershowidg'ttib•name of sob•conpsctors'�and state wheibet or not;those entitles have
empty" . It:t `*ik*acfp tt .•,d!4!:titt tip*144'iii wo ara'.aotnp.po1ic nun*tr
40Milyt eni lb r�thatlls rovi . ":workers'co policy andjob:sit�e
,i' J'e P :� mpensattean.lnsierance fear �3'ees« Btptaw'ls-tht;
informat ,n.
7nsuraitce Corifpany lathe Ai3FAOW MUTUAL.INSURANCE-'COMPANY
Poticy#or$elf=ins.Lio.,# ''9.D9A Ei tziratiombittc 0'I/O,112,q, .
a Job"Site Addressc) N City/State/Zip
\ Attach a copy'oithe;wurkers:.compensation policy declaration page{showing th po cy number a nd cxpi, &en date).
- Failure_to secure cover _as ntn$d'under MOL c.1;3.2,115A is a criminal violation:punishable by.a_ftne xip-td 1,500 00
and/or une-ye;ar ititprisntnent,:as well.as civil penalties in the form of a STOP WORK OPpEit fibre:df up'tct 510000•a
day againsvtho,vtolator:A copy of this statement may be forwarded to the Offti e of°Investigations.of thc DIA to nisuranoc
coverage ve:nficatiorl _
Ida ;-_ ..e+er z i F 1 ems ,.Olt," of ioi f�n7li at heI t fort atelir+ i 1s SOM: a re>i Ori 'c
1 i
n , ` . `ts
st�, ,sate,
509T78
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` , Offlcial'usaonll. Do frot write in this area,to be completed by city or town Official;
City.or Town: PetmitlUicease#/
Issuing Authol'.lt :icircleOtie) .
l..B,oard'of-Health 2."Building'Pepartnieirt:3..•CitylTowh Clerk: 4.;ElectricaI Inspector 5 :Pl robing intit.ector.
0..:.Other
Contact Person;: .. Phone#t . .