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Home My WebLink AboutBLDG-20-002723 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ",1;=�E � CITY YARMOUTH MA DATE 11/f)7/2O19 PERMIT#I`/"a0'^ aA Co 3 JOBSITE ADDRESS 60 BROADWAY UNIT: 14 OWNER'S NAME ENGLEWOOD CONDOS G OWNER ADDRESS WEST YARMOUTH TEL 781.258.7564 FAX TYPE OR MICHELLE COLLINS PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL,[ CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: GI PLANS SUBMITTED:MI YES El Nth] 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 I 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 RI NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY g OTHER TYPE INDEMNITY El 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 tr 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 comf ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE# 12298 SIGNATURE MP g MGF❑ JP❑ JGF❑ LPG' ❑ CORPORATION[I# 3281C 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-Comr(t)nivealth of I►Mass ckusetts f_l; Department..11eptiri*ent ofirrdustru dA ents i ,':-i: 1 Ctingress-Street,Sulite 100. 1 -- ''. Bost©n,MA02114-2017 wwwmassgov dia Workers'.,Compensation Insurance Affidavit.Builders/Contractdra/Electr-icions7Plumbeir.. TOB.E P'ILEii~WITH THE-1ERidIrr11`IGG AurlioRITX;. .ADp[ieantfinforunation: ., Please Print aitiblli li e( s ti r• `.'' ,oulb di,,vtd : .N/(NSLOW PLU MBING cHEATiNG CO„iNCG ' add ress:4 EARDON CIROL>" �". �SOuTH\ARMQUTT ,MA_02664 508=394-778 ._.. - Fhtirre�: Are yousantemployer:Cheek theappropriatabox.. Type of t o ect t nIC , -. employer With,8 ...employees(fell'°andior part.time). 7. ❑`New construction •2,O J.am a4cle ,o tbror h t and have no employees•working for me in 8. Remodeiitlg: sny"�ct'�CNo `comp hitiiutattee requited l 3,D T an a"llom owner doingali;Work myself into=workers cep.insurance ired..? 9. Q,'l molition 4:Q,I.san a h wnerena Willi,eliitiesepo motors to;conduct all workyon my property. I will; 10 0 Buildi'ngaddition- ensure"thatalt aortttaottor�t eitherhave workers'con pensation iasuraneeorare sole Q 11 Electrical repairs or tfbns • propdetem with no.emptoyee s. 12. P[umbin or.ati iiit#lob's ❑ g . 5.1:1 tam sot.te dtemah'eetorsnd.I htavcbiirod•the sub-oontraatorslistetl on tlheattached sheer -- er4.. TheseThese-sub-vontt torehaveemployees and haveworkes'comp,imutpci.t ❑ es . 14.0.Oth .6.� eat a6o, aot=ed r of oer ve axe ised•theii ighcdPuemqtn.pMOLc. t 15240)and we have no employees tso workers•comp,insurance required:) `Any aPplic an"l#hdreh #tYitMsf ii:tiOlIt'ciiit,the iori_befow showing^their workers compensation-policy infomia on . t itop owners who relmiipt nfi'tdavitl ndieatmg they ere doing ills work artd:the n tire.Outsicieomitted*ipoust sutinit-aaaew,af idavit-mdiesting suctt. tCaca�t►il s that oiie dt*e,6 x must ensured an additional shcerstwwing the paine of ihesnb-conttactootart d state-whetifitei riot those entitles'have Oni14ayces. _.e' as e :thait'lwstprovidetheir workers'camp pabc'!!t! .. , Iarmaneorployer l atisproviidingworkers'compensationinsuranceyor"nyeutl?tloyee&. Belowis>"thepolicyattdjop.ems. inforriation. Insurance Coin pony ARROW •MUTUAL INSURANCE,COMPANY Policy#or•$elf ins.Lie.#:1.969A .. Eltpiration Date:01101/ .020 \� Job Site Address ..City/Stnte/Z\ : .- ks„..,...,,,. � Attach a copy n'fthe'viiorkers'compensation policy deielaration page(allowing the policy number and expiratvtiia.date.Y. Failure to secure cover ge as required under MGL cc L52, A la.a criminal violation punishable:by a.f nnup to$-15• 00 00 and/or one-year imprisonment,,as well as civil penalties in the form of a STOP WORK ORDEl andva finer df up to$250 00 a day aoainst=the_violator A copy of this statement may be forward"ed'to the Offi'sx ofJnvestigationa.ofthe DIA fir insurance coverage verif catiap, . I Flo Hereby.carets;{-uir , o:rage ,.Ivies of per,jury ihatlhe infontiattonlIro-Olikil a'e ds.trtie and correc▪t Signite: • •,.. Date: Phone')k508;3,94-7778 Official use onlic Da not wrrtolit.this area,to be completed"by cify'or town g f claL; City or'Town:: Permit/License Issuing Authority(eircle One): 1..Beard 0'IHealth 2'BiiildingDepartmeirt 3.-C ty/Torvn Clerk 4.Electrical Inspector 5-Pl t nbinglnaplector 6Other ,; ContactPe7rson:. , �. Phone#: