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HomeMy WebLinkAboutBLDG-16-000294 . 1 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PIER„ IT TO PERFORM GAS FITTING WORK ©� ( Q CITY X rr c " �`-f, •C.,L� MA DATE elf'7 it.--,._.. PERMIT# '�b l4_,.- 07 Y._ JOBSITE ADDRESS, 2a ••l a ic )g 9c) _c. - :OWNER'S NAME (��}�o�` i .r VY)C\ GOWNER ADDRESS Sa r N. TEi; Io-97 -a) FAX, • . . TYPE ORJ - PROT OCCUPANCY TYPE COMMERCIALS EDUCATIONAL 0RESIDENTIAL ' CLEARLY NEW: ;` RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESl0 NO • APPLIANCES 1 FLOORS--I BSM 1 " 2 .3 4 5 6 7 8 9 10 1T 12 • 13 14 BOILER I1.,. •,, t ! - I ._._....z_I.,....,.:.f.,__..i_... _I'. .1 . •I . " • BOOSTER ..:,.._.. f I ... .., -:•, .I t _._._I . . _I'_ ._..I_,._._.f. :._.I.._. ._1 ... ..I I. _...f J CONVERSION BURNER ........ . .-1..:.._,!, ...f.: ......f_ ..1. ...- .I..,.., „$:.:.:.I..,.,,,...I.._. ..1_.._v�,f.._. _I -,..,1,....... I COOK STOVE . _ _... • .. ._ .. . . -. -.. • • • • • DIRECT VENT HEATER - .J••.'I I ..i ._r,. .I .-. .J , • 1•_- .i• .. , ,._.I , ,j::„.. I=.... .I I .�...w1 •` DRYER • • ...1::. FIREPLACE • #• .. ..f I _...:..,f • .; !.:.._sm.< : . „I Ili i ... _I—...�..5 FRYOLATOR 1 ... f FURNACE �_ :_ ... _ .... .,J _ ° ... .1._. . �. ...J I . - GENERATOR 1 f __ ( "; ' . ` . . . GRILLE - .. . ! •. : ..J ...., ,! �.,,.�� ..... .1 _ -.�.(..,.. ..1 __ .1 INFRARED HEATER _ I .I( II .I„...( I Mr.,• J LABORATORY COCKS : _.,MAKEUP AIR UNIT ' .. - . - ..• :. i. . .I t �-1-..• -.. . ::-.;-1_ ...f f.... i .1 . ...I i* • OVEN • ._._: • .I . .. I 1 I . .w.... . . _..k .._..t •..'1 .. __.1.....---:—:1 • .1 ..�..,.:_f POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT • ,1 ._.._ _ ! _•_I i. ,...J M # .. . 1 _ . .J ..,= 5 ,_^# ,a ..f .,... ..�.._�1 TEST n..- UNI UN EIREI tTvl FAN " 1 .....4,_ . __1 , .-_1 .._._I.,__... rf __,_ _. ....I ._. r 4 :..._...I _--1_..__..I WA ER .I ...._..I-. 1 I 1 I -j-- f -._I ,-_,.,.I .I I _.._. I t - r' /4 J/ r. ._„ OT ER • 1��� 0 • . __ - I `. �.. - ��._. ._. ..._ _._.... _ -_._ .. - - 'aL ' . . a,..�. '_ _,_.-I.._.....J I .......i _..�.,I_ ..f ,I .. : �1_ .,... .J ... ..1 .,.. J . f_____1. .....-.! _ l I .. ...1... ..J..__ ._f_.......:,1 J, f I _i .I ....J .. I I . . .I ... . I_ ..`..s E Ji D ` (J 1 i I ,...._. f ._...I _....I ..I ,_ .. I ': J I I I "y _s"{ INSURANCE COVERAGE .0. I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 r NO :..I I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY •.!.-I OTHER TYPE INDEMNITY .`.._ BOND 1.. OWNER'S INSURANCE WAIVER:lam 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 .-._,f AGENT!..,,,_I 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 compli nce with all Pertinent provision of the Massachusetts State Plumbing Code and,Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME: S•T•EP• HEN• •AWINSLOUV,.. lij4J - . ,�LICENSE#',••1229g.,� �� SIGNAT RE MP:.✓..XMGF 1,..J JP'‘,_J JGF i., .I LPGI .- ; CORPORATION ✓ #13281C ,,__y:J PARTNERSHIP ...•#_..•- ..• .. .1 LLC I#i f COMPANY NAME: E.F,WINSLOW PLUMBING&HEATING I ADDRESS i 8 REARDON CIRCLE I CITY SOUTH Y.ARMOUTH I `1 MA +STATE I ZIP 02664 ..,...r-..,., ••- •tTEL{508 394-7778 ..-•. . FAX 1508-394-8256 . CELLi 1 EMAIL,ACCOUNTSPAYABLE@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents G Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 ..� ' www.mass.gov/dia • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): E. F. WINSLOW PLUMBING & HEATING CO.,INC. Address:8 REARDON CRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 70 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling shin and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other 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. 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. 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 Policy#or Self-ins. Lic:#: 1794 A Expiration Date:01/01/2016 qq y� r Job Site Address: c,( 1 f v shop .S City/State/Zip: 67, rn : 1 C`x`r 13 + Iti 1r� �a� �,N � y3f,lllC '1�+r Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of t e DIA r insur e c verage ve • cif n. I do hereby certifi,under pains a'.d penalties of rjury that the information provided above is true and correct v 2016 Signature: 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#: