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Home My WebLink AboutBLDG-20-002727 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =="'_ YARMOUTH CITY MA DATE i i inwei A PERMIT#"06,-ga—C7.22 JOBSITE ADDRESS 60 BROADWAY UNIT: 20 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❑ NVI 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/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 Ri NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ig 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 corn ce 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 E( MGF❑ JP El JGF❑ LPGI❑ CORPORATION 10# 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 Commbrtwealthof Massaeltusefle :,Q/ Depa tme ltafIndust.. .: .l: ' ' ® 4-,` m, Congress Sfree4 Sum 100 i a Boston,MA 02114-2017 • - .,., wwrv."mess gov/dia Workers'"Compensation Insurance:Affidavit,B*ulders/Contracton/Electncians/plumbers,. TO"BE PILED 4wriB H- RMLT'11NC•A `HORYTYc: AnpC ant Info ation Please hint.L biv~ Nu t.:1)3 etsto*niatt ' dash:E f.W O-St W PI UMBINGiBME=AT1NP C©-,1NO- ' Address*.8"REA D)N GIRO...E. ` tylState p.S UTh YAfiI44Q.U"CH.MA.02664 .Phone; :y50&394.177s Are,you an employer?Cheekihe aplrop box Type of pro ect(r E iflred)< 1 f am"acrnp1*ye wills 88. empraye�s(fulraadlor part=tuna)! 7. Q;New c nstruetion 2,Q T an-11110 c l ele er p nersit.ip..and have no empllyees'workiag for me in $. 0 RelObttelitlg: aoyespaQilX [No.wxtrlCers?comp.3nsuianae-tequiced:] " 3.0lam alieteepwner,doingnll work-tnyseif.[No-workers'comp.iesurance required 9 0:Deitiolition 10 El'Building add>itielf 4:E31 apt altmitownerandwill"bolunrlgeommotorstoconductellWbrkoa'myproperty,. 1"will ensure thattall Conti tars,eittie r have_workers compensation Insuranoa,orare stile 1 1.-011ettdeal lepairavetaddilibris proprietors with np:employe employees. • 12..0 Plumbing repaits:or taldttiioiis • 5.0 lath. ,l co ntratior•.and I heyel rrsi.the suiNtoittmoMrallsted on the attached sheet n-Ellteitif airs' Theuo au6-oontractora'havme;lnpt'oyees and nau havo workexa'comp, raiee.t 6.Q=W aieaootporattt of:and it otfiaerslawe exernised theirr'igt tof-exemption:perk4OL.a. 14;0Ot�1 -, 1524.1(4) acid we have no*mployees.[No workers comp;,insurance<tequired:) -Anyappi anttliatbhe css c'#rl must ,411out the:seot otnbelow showing-their wad a st cort gtsation pokey ulfe? on= t Ho warct who su it this affedavitladrea$ng they ate doing all wont and,thenleim.outside contractors must submit-anew:6fifdavit`indl' flg such. 4Contraclots"thata checktit bo annstatt ed'an.additional shcersbowulg the name ofthe.sub-coaritractootend state whetter or not those entitles have einploYccs. It4641 b gt ►rs lo), the,must: videthev w ':comp po `!t , _ . lam-go employer�that Ist pros ing workers'compensation"insurance for niPeyes~tpl Below is the poi cy and job site, inforniatdo r. Insurance 4ottfpiatty 1Fame ARROW MUTUAL.INSURANCE COMPANY Pelicy#orSelf-ins.Lit #:1.909A _ _ E tiiiratiombate:91`I.O112(l2p Job Site Address. . ..Cit!/Siate4ip. _ . ., ' AttacksAopy OftheAsOrketV"compensation policy dedaration page(showing-the policy number and exp ration'date). �\ Failure to secure coveragesas required under MGL c. 132-,. 5A is"a criminal violation:punishable by a line up'fo$1,500.0Q and/or one-year imprisvnment,.as well as civil penalties i in the form of a STOP WORK ORDER and4 fine of s'tit S250 00 a day against the violator A copy ofllus-stateme nt may be forwarded to the Office-of Investigations oft1 a DIA for insurance coverage vetkeatioti. �. 1do ,ceQ ''� alt�"7�rt+ v c, R a. � ebJr , �'" tl p "" �this df-prr�.l'rcr�`tlatthe litiurilt�on�ii+�iyided iirii4r►e.ftri°tre'irnif c�orr� Si a " ; -% "Date: Phone 50 94*7778 �. . eial use only. -bona write in this area,to be completed by cl&ortown(Oda L \ b,f City or"Town: Permit/License# Issuing Authocity-(aircle One): 1.Board cifHealth 2 Bii lding Department 3.City/Ti wn Clerk 4.Electrical"Inspector.5.PluiinbingIuspector 6 Other ContadtPerson:. Phone* .