HomeMy WebLinkAboutBLDP-16-000161 (2) MASSACHUSET.TS UNIFORM APPLICATION FOR A PERMIT Tf O PERFORM GAS FITT. NG WORK
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JOBSITE ADDRESS �(c� C�()C�� f' 0,, i. :OWNER'S NAME/ , 0 p(' . rujo r, ......
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAPRINT
CLEARLY NEW:0 RENOVATION:Q REPLACEMENT: PLANS SUBMITTED: YES CI NO
APPLIANCES 1 FLOORS--I, BSM 1 f 2 .3 4 5 6 7 8 9 10 11 12 • 13 14
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ROOF TOP UNIT
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-- - - INSURANCE COVERAGE .f
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES I d NO I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY •..+1 OTHER TYPE INDEMNITY "...-.1 BOND I._
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 ___,I AGENT Li
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 compliance 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.,I s- SIGNATURE
MP 'XMGF l->_.I JP .,_J JGF I"J LPGI .. , CORPORATION i 20 13281C _<..,i PARTNERSHIP ...'# i i I
COMPANY NAME: E.F,WINSLOW PLUMBING&HEATING .ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH • 1 STATE MA I ZIP i 02664 1TEL 1508 394-7778
FAX 508-394-8256 I CELLI . IEMAIL;ACCOUNTSPAYABLE@EFWINSLOW,COM `
The Commonwealth of Massachusetts
r
Department of Industrial Accidents
-�tli► ! Office of Investigations
WV,r; 1 Congress Street, Suite 100
Boston,MA 02114-2017
°v� 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.
.!
8 REARDON
Address. 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.[1:1 I am a employer with 70 4. ❑ I am a general contractor and I 6. El 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' �;
[No workers' comp. insurance comp. insurance.$
9. ❑Building addition
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 12.0Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 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 P +i
Expiration Date:01/01/2016
Job Site Address: C g V s os City/State/Zip:t J * r/y(p c 11 1, Itt -�(�8
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 tlIe DIATAEir insure verage v7piliqon.
I do hereby certify under pains a d penalties of rjury that the information provided above is true and correct.
Signature: — Date:
2016
Phone#: 508-394-777g
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#: