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HomeMy WebLinkAboutBLDG-20-002610 I . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK , .�_�' ` l MA DATEL I CI 1 PERMIT#s�&sJ° - -•=.,l�f_= CITY . fir�C �s�l`1,...�_..�- ��.7..��..�.�.. JOBSITE ADDRESS -•-. I- . c _ _ --- .•' OWNER'S NAME I Inc),I`a --Lis- - -{ GOWNER ADDRESS .... .piI -_E._ ..._.. ... __—._- TYPE ______OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL 0 RESIDENTIAIe PRINT CLEARLY NEW:0 RENOVATION:E] REPLACEMENT: PLANS SUBMITTED: YES NOM 11 �1 ._,_,- ___-� 12 13 14 . .. _ —.- APPLIANCES"1 FLOORS-4 BSM 1 2 3 4 s s 7 8 9 10 BOILER ! '�MW�S --- CONVERSION BURNER L® IM M� COOK STOVE 1i1_ ®Il.----.- 1 M - M ___ FIREPLACE O A O• _MMONION0111.11101111110111011,1MilliiiIIMIMI FURNACE IMINANIPPMINIMMIINIMIlliltlimiMINOMWEI - GRILLE UMW Min .._. dinallimini11011 no el _ :MOW I . i.._.I' ,. . - .. INFRARED HEATER : !!! _. _ _ i _ __ . .., NM mum OVEN 0I 1 - -_... � _ — . .. . � �w. migI Room/SPACE HEATER 'r____S_Mlli IF01 I OP UNIT - -- .-_hi • piiRiU.!!. iR- INSIMILIMMIM TEST I,�__ UNIT HEATER UNVENTED ROOM HEATER ,1 h! f ! - WATER EATER W `�M11111i OTHER '�M - ' leWl,win i.... -1 1� C; . ....._.._.... . . ... _-- . . . _.._.__. .! 1*1. . 1 ®.1wJ111111® lillAill INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES pi NO [I 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY al OTHER TYPE INDEMNITY El BOND E • D_ .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 Ei AGENT 0 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 compll je 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# 12298 _ IF SIGNATURE MP 0 MGF D JP© JGF 0 LPG'0 CORPORATION Q# 3281 C-__, _ PARTNERSHIP[]# .- _ - _ : LLC 04 ...... .. .1 COMPANY NAME: EF WINSLOW PLUMBING&HEATING ,,ADDRESS 8 REARDON CIRCLE CITY SOUTH-YARMOUTH ,�,y_..________ STATE MA `ZIP 02664 TELj_508-394-7778, FAX 1508-394-8256 I CELL NIA _ EMAIL[ac countspayablei efwinslow com . _.__ . • / 0- 9c0 °D . - �' _ The Commonwealth of Massachusetts 4 a _*=, 1_ /, Department of Industrial Accidents _9=f1f1, 1 Congress Street,Suite 100 _11- Boston,MA 02114-2017 Jrue: www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly 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 an employer?Check the appropriate box: QQ Type of project(required): 1.Q✓ I am a employer with 88 employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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. If the 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 ---7i Policy#or Self-ins.Lic.#:1909A Expiration Date:01/01/2020 \ V 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 oA coverage verification. I do hereby certify and a pai s nd pen Ides of perjury that the information provided above is true and correct t Signature: 1 Date: Phone#:508-394-7778 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#: