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Home My WebLink AboutBLDG-19-005825 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK WEST YARMOUTH 04/04/2019 6/ =�=tE� CITY MA DATE PERMIT# G—�/ � JOBSITE ADDRESS 60 BROADWAY STREET UNIT#20 OWNER'S NAME MICHELLE COLLINS GOWNER ADDRESS 141 SOUTH STREET,RANDOLPH MA 02368 TEL 781.258.7564 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL WI PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[ PLANS SUBMITTED: YES❑ NO R. 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 1 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 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 [v7 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 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 com•1:nce 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: SIG(1_21,Adevet,, TURE MP g MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION M .# 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 #498355/ PERMIT FEE- $60.00 U` i1 (J The Commonwealth of Massachusetts ' E Department of Industrial Accidents 3?Ifll_ 1 Congress Street,Suite 100 __ty= � Boston,MA 02114-2017 ✓'>; -, www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name(Business/Organization/Individual):E.F.WINSLOW PLUMBING&HEATING CO., INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you as employer?Check the appropriate box: Type of project(required): I.EI i am a employer with 86 employees(full and/or pan-time).` 7. ❑New construction 2.0I am a sole proprietor or partnership and have no employees working for me in 8. Ei Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 30 I am a homeowner doing all work myself.[No workers'comp.insurance required.] 10 Q Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 1.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.oRoof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. lithe sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lic.#:1879A Expiration Date:01/01/2019 Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine 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 of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the an p allies perjury that the information provided above Is true and correct. Signature: r ...o� Date: Phone#:508-3947778 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#: