HomeMy WebLinkAboutBLDG-20-002726 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
_; = YARMOUTH Q
__t_i_ CITY MA DATE i WOnig PERMIT#A01T"� 720
JOBSITE ADDRESS 60 BROADWAY UNIT: 18 OWNER'S NAME ENGLEWOOD CONDOS
G OWNER ADDRESS WEST YARMOUTH TEL 781.258.7564 FAX
TYPE OR MICHELLE COLLINS
PRINT OCCUPANCY TYPE COMMERCIAL❑ ❑EDUCATIONAL RESIDENTIALp
CLEARLY NEW:El RENOVATION: El REPLACEMENT: ❑ PLANS SUBMITTED: YES El NRyl
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 g 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 El
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 El AGENT El
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 e with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `
PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE# 1229 SIGNATURE
MP g MGF❑ JP El JGF El LPGI El CORPORATION 12# 3281C PARTNERSHIP❑# Lc El#
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 n�
The:Commotioet th ofm0 sac usttts
- /F Department efriithi$6-1(1.14.044entt
r I,Congress-Silreel Sum 1a0
Boston,MA 02114-2017 •
www ma3s gov%dia
Workers'Compensation Insurance tiarvi Btinders/Conte"actorsfEiectriciaus/J'Iui'nibers.,
TO B.E FILE1 n.ThE PFR reiG AI OR�ITY Annl an#] fe sciba: please Print.rLeeil►ly
Nbtri (Bu ea Jp�g t, t rxnl ►d� rd�at):�f.WINSLQ41 PLUMBINGA.HEATINC
Address t3:R a ;CIRCLE
k Sally f A$C}UTli MA 02664 -ph. ne#.508= 7 .8
.Ar gyttu;aacniployhr3 Cheek the;Appropriatebox: profect(required):
• p • Typ e of
I s i°am-a=e 'cr titif-88 eanployets(full•an ilor psrkirne).• 7. •❑New construction
mos ±Ie+ p i etffiIiWauihip snd;have po etriptiynts working tor me
8. D
any caWc►ty 11Nawtuireus'comp innotnce required]
Rtod`eling:
I 1-am ahtitn wner,doirt ti work m" .r a-wor401' insurance ted:0 9. D Demol Lion
•
10(]Buildingaddt
D tcdn•
4 1tsm a lint oWaerand will hel inrtg..cantraotors to conduct all work in my proporty_I will
cnsu ntlut4ll:oontractorgeitherhave.workers'compensation insurance or arc note 11. El 1ett1 or:BdditibnNe •
tiroprieta s with•n4 artpitq es
1 a.D Plumbing repaits`.or-Omens
5 la
th am a- contr tar and.Lhave)il ed;the sub=contractorIintid on.the attached sheet
Thaesub-contraetore'have-tnplagees and have workers'comp.imiumaee.t l3.QRegt.rcelair5
14
•
6�'-�ir4aosa brettottend tSiflige>rs hevc;erXeteised•theu�ttgtit of-euemptroa pert�tGL a Dothter,
era°havauMennplOyeei.[Io vnoskcis camp.insurancotequlred:J
4Atiy fp ilit nttlfs ah biii i mu st s'lllloutthtea orlbetow abowinttheir vtorkers'compe tion policy iafoilentlem
f llomeaw,iq.!who sttbopt t nidavit Indicating.they ate doling allawork add tbenliire outside contractors must submitssubmit-anew:Qftidavit iadicating•such
CCopt}*ctots that 410k this l oievrrtust attagbed an.additional sheer�sbowng'th me ie na of thesub•contiactors�and state w: hetlierr ar not those entitles have
t`inploytros.Tft16- lora:have� e workers':co up polic ala0er
f 1 atn ae entpleyer that'is pro ingworkers'compensative-Insurance for mynitiployees« Below1l*thelwll antijob,s e•
infornatdon%
institoof ed:_x panywairte'ARF VV,MUTUAL,INSUM.- IOE CUMP4NY
Policy#or Self ana.Lie,#:1.909A E ipimtton Hate.01/01/2020
Job SiteAd4res ,... 'City/State/Zip:.
_ Attach a.iopp»ftte.WOrkers4 compensation policy declaration page(showing-the policy number and eicinnilon'date):
Failure to secure coverage-as.teguire4 under MGL c. 152,§25A is a criminal violation punishable by a.#ine-up to$1,500 90
and/or one-year imprisonment,as well,as civil penalties in the form of a STOP WORK ORDER and:a tinescfup o 50.00 a
J day againatibt?'-ijoiatut,A copy of this statement may be forwarded to fice-of Investigations.of thA for i suranoc
coverage verifieattoit._ .,
l do hereby cert$Wwua • .tt " . '!tees of pert fiat.the infbrinationproritiellaboveirtintand corm
signat tret rc e :_, <Date.
•phtino S084I 7178
Offidul use-only. Da not wryite in this area,to be completed by rb'or town offieia1
City or•Town; Permit/License
Issuing Aathorits(tittle one):
1.Board;ofHealth 2:Soil+dititgDepartment.3.City/Ttitv i Clerk 4.•Eleofrical Inspector'5 Plu d intritspector
6..Other
ContactPerson; Phone':*