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HomeMy WebLinkAboutBLDG-17-006306 _ _` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK , — CITY PY, -. __,__ ---u; MA DATE)6C ?/ i,' ;PERMIT#"246 J7 6 OG' JOBSITE ADDRESS10 .64 oAt iii t ig 1 OWNER'S NAME 4 Q. © OWNER ADDRESS l� �j _ TEL �� r `(� yti Pi T L 6 J, YX SFAX{ i • PRINT OCCUPANCY OCCUPANCY TYPE COMMERCIAL® / EDUCATIONAL® RESIDENTIAL f N CLEARLY NEW:D RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES® N0 Kti \ 1 OPR CES 1 FLOORS-0 BSM 1 ' 2 3 4 5 6 7 8 9 10 11 12 13 14 ' BOOSTER l wt 1__1. 1 , T ntaMaii CONVERSION BURNER ._ t I ( il•• t' `' I i f i' I COOK STOVE �- 1 I . -- 1 DIRECT VENT HEATER 1 1 1 . . _,i "� 1. DRYER -`" I. "" ' i-- � t FIREPLACE :-- '- --. --1 - FRYOLATOR 1-"--.. . II. I ..i ._1-_ .. - Il_Mail FURNACE II_ ! ..t l l - GENERATOR 1_- - r --_I I. ___ S GRILLE I . cr f ! ; II ... .. .�. _ "I 1 - .I , INFRARED HEATER ILL .,� `i .LABORATORY COCKS • -,Il .• - , �i . ' '- = f MAKEUP AIR UNIT ( -- - ! I .__ i- OVEN .. I I - - ,. POOL HEATER .�,.-' 1 .' K .,... t _ ._ I , .. 1 ..... I _ . �i ROOM/SPACE HEATER t ... : ' 1, _.. T 11 . . . .1' I,..1 )�I` i ROOF TOP UNIT -.-_ _ _t _ �- _ . t ' TEST I `l'� ` �I UNIT HEATER .L. i _.. :. a .. -. ._ : ' _ UNVENTED ROOM HEATER ,,! ' r . t„�R� t WATER HEl hr t . �i OTHER F11 ., se ra_ _NM "" —� —.. _ . a"ill__ -- ,110114, . -„I-7' --.-Th Mt ,. .' ..NOMMWilli • INSURANCE COVERAGE I have a current liability insurance policy•or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [l NO E I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY 0 BOND 0 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 D 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 a 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 ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �iscC----` PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE# 1229 SIGNA URE MP El MGF El JP El JGF 0 LPG!® CORPORATION E# 3281 C PARTNERSHIP # y LLC D COMPANY NAME:IEWINSLOW PLUMBING&HEATING ?ADDRESS 8 REARDON CIRCLE 1 CITY I SOUT®OUTH STATE MA IZIP 02664 ITEL 1 508-394-7778 FAXI508-394-8256 M CELL NIA 1 EMAILlatcountsp able(c�`efwinslow.com - Department o Industrial Accaaenes *— =- i Office of Investigations Fines 600 Washington Street _'1:= ,-..-• Boston,MA 02111 • .s ....0www.mass.gov/dia ' Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly • Name(Business/Organization/Individual): L•.`r•W 1 AS OW Q(khNJO t' ,t L lI�.al Qe, I viC. Address: ' Q o I) ( tkQ- U • City/State/Zip: SoAV\ w,o,c MP Phone#: 5S-3a4-1'17S • Are you an employer?Check the appropriate box: Type of project(required): X;, I am a employer with '70 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors Remodeling 0 I am a sole proprietor or partner- listed on the attached sheet. 0 ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition 5. ❑ e are a corporation and its [No workers'comp.insurance 10.0 Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.❑Plumbing repairs or additions �.0 I am'a homeowner doing all work c.g 152,§1(4),and we have no 12.❑Roof repairs - myself.[No workers comp. .ees em to [No workers' insurance required.]t employees. 13.0 Other comp.insurance required.] \ny 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. Im an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site rbrmation. /�� —_ rsurance Company Name: t'rrep• Ckv k CA1S WC&el(ILvici olicy#or Self-ins.Lic.#: 15 a 1 A - yy,, Expiration Date: (---1 — Doti • )1:,Site Address:, 3 r''�W ° 1' I C s rn`r City/State/Zip: O�Lib 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 rup to$250.00 a da a:ainst the violator. Be advised ,=t a copy of this statement may be forwarded to the Office of • tvestigations • the DIA for insurape- ;•verage veri•• •,on. i do hereby cert J u ' •e ains an;penalties o Fury that the information provided above is true and correct iu atu3 CC =• I... ` —AL— Date: ('el. i 1O1 hone#: .S[_1.254- 7 77X 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#: