HomeMy WebLinkAboutBLDG-20-002725 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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_` I YARMOUTH �' n ,�
tdf CITY MA DATE 11 ro7/2ni q PERMIT#/';r-6W7RO ol7Pr
JOBSITE ADDRESS 60 BROADWAY UNIT: 15 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: ❑ PLANS SUBMITTED: YES❑ NQ ]
APPLIANCES 1 FLOORS-0 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
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES RVj 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 t e 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 co liance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE# 122 SIGNATURE
MP g MGF❑ JP❑ JGF❑ LPGI❑ 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 accountspayableaefwinslow.com
WORK ORDER 515238$50.00
The Comrretinwealth ofMErssopus is
Ak
,� m�r Dep; ielnt ofIndusd to enis
e '' 1 Congress S ree4-Suit 1'00
aiii .. Boston,MA 02114-2017 .
,rz;,c, . 1Vw .`lma sgov/dlla,
Workers'Compensation Insurance Affidavit Biuiiders/Conf aetdlit s/EIe cians7Plu tubers.
TO D :FILED WITR-THE PERMi'I ripe •A IORITY:
AnnHeant� nifoiimatbon Please nt Lree biv:
N e. ntsiti � '' t iidivititiatl. F:W11�1SL�OW PLUMBING&H.F 11N6' ;LO..:INC:
Addressr 8-REA t001>t e,-IRO- LE
Cityistatei p' SOUTH YARMQ.UTH.,MA.02664 phone#.508=394=7778
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AR.you an employer"'CheCk fbezppropr box: • elf.'imilect(requjted)t:
1 xi m=a;em}iIo�+erwtui $ employees(fillltifld orpari fime),* 7. C.]Ne*:Ceflist'ruction
2- .' -.aat;asoi .-re ,e� .
�d. �► {fr► .p�g!and.hava ao employees rvwkipg for mo in
any capadity INo workers'comp i»snrance required) 8 []Remo i0hng;
1•ant Whoteeoyine,desert worst 7ayaetf-,No Voricete ecmpAnsuran ee quirrd14 9. Demolition
10 0 BuuildgadditidtkdL11;ma10rnem w ani v141:alnng?otttraotars to;toodoctetivtrken my property, l rill
ensure fh914poYlt# o�attlier two:warkds'compensatroti laeotefCeor arcsole' 11 El lca e o a mint
proprrotetivith no.employees. 0. p
.E Pltunbh g rep***
12 4so0 .
501 am aleiierdl.tay5p,Ctor And I hi a tho suli coigraatots'l d.on t e attached l
I3.p f. , ,
fAesaagh tiontra4Ebttchavenploy!ees anii have workers'con+p+lndupnce
lircama►` lttt haveencertrisedtheu 14. £r�ltkher ,; .. ,<
empooe perMGL:c:
{� tmrpbma artli t�otfi�rs �t af-ea..
152$l,C4),andwe haveno-aitfployeea.(o workers comp;insuranc:erequired)
'"Anya1 Bean ss6h�b*l`enust` so`'Ill)sut;thek otibelaw shownngR their woktcers commpehiatiott policy m[Oiltigin: .
t Hams owfler$Who+submit thu atI"idiMt Indicating;they are doing alt.work and then hire.outside contractors must submit a new:dtfittavd i dicaling such
tConpacterslltats.otteele this Ortust aivaohed an_eddittonal.shccrihowiog`ttie none of the tractontait'd state wlt tler'ol not those entitles"have
employees.I have np'Ioyee& $!rr kpmvidethfu workers":comp. .nu#q er.
lam 44 employer llr'atgis.pr. 7vorhers'compensation insurance forfoeMpeittplopeei,, Below it the pntic,a ,00b;site
information.
Insurance C mpany;Natxte:ARROW MUTUAL INSURANCE COMPANY
Policy*or Self ins:tic,#. 9.09A FaciZration Dater01101/-2(120
dob SiteAdcirtrss ., r,City te/Zip:-._ .,
'-' Attach a copy o liC:Workers'compensation-policy dedatlation page(showing.thepolicy number amid expir>ition'date).
Failure to secure;coverage-_as xlui ndet MOL o;'L52,,{025A is a criminal violation_punishable bylthuxup to$4
—C . and/or one year imprisonment,.as well:as civil.penalties in-the form of a STOP'WORK ORDER and,,a f e tf :to 04004
day against thesvtolato A copy of this statement may be forwarded to.this Offieo of Investigations of the DIA for insurance
A coverage v0: i' oP:-. : . .,
14 herels i--ems'- ut '-dp '-ribs ofpen, etr}''ticat a tiajbribahtori ii6Oliteijtir i true itr a a i ear tt.
Signat�e �.: "' , - _ -_ Data:: - � "�
,p �\ Phone#°8-894m8
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• D,f flda"t'use only,bo�no ru i rtl'e irt'rli s area,to be complete l'by-city"or loivn of iCtid;
` \�
City or Town Permit/License#
issuing Authority-( &ale once):
I._BoardolEentib 2.Building Department 3.;City/Towiit Clerk 4.ElectricalInspector S P10:Mhing:inspector
6 Other
COfltaCttPerson::. . - - Phone .