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HomeMy WebLinkAboutBLDG-16-002538 oft% UuG '' /24 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ©�L ,,,, CITY- %Li YcxIl 1C.)rn ._i, MA DATE. IL/O.... 1 PERMIT ._ • .. ..... Ik•i: 1- Rd .OWNER'S NAME._Sty-1 C.ULC.�Z,_c.-!X.._. JOBSITE ADDP�ES S�J�Z� i ' % . _—..__. GOWNERADDRESS k . .IJ Y_.S.1..A.1.Lor'nMA.62.'t7`rEl.;(P03:766-.Z`7O 1jFAX, ,-_-.-;._- • TYPE OR OCCUPANCY TYPE COMMERCIAL° EDUCATIONAL IQ RESIDENTIAL PRINT. CLEARLY NEW:E_h`' RENOVATION: REPLACEMENT: .• PLANS SUBMITTED: YES C NO ,,,x< • AP PLIANC ES-3 FLOORS- I BSM 1 1 l"2 I 'a 4 5 6 1 7 1 & I s 10 I If• I 12 I. 13 I 14 BOILER I.�.�_..II .-=1=.�:_, _I„__-_,1 ..L_ II-__il _., , rll_-. 1 . BOOSTER ..0. ...D.: -. :IL .1 .1 .1.......i. - • ___.1...,,,,....1 - • • .f CONVERSION BURNER • -- r .:. .<i1• ... 1 ....r .EI. FIy .,,l.< II_. ...I. • I _._I„ -I J1. .. COOK STOVE • I' -•.I ..v1I-_-_r1I... .-I .,:. 114 1- - , Ir ,11 -=F ..-•:I1:¢. €":„•-_._~' , . 1-... :[ :1 DIRECT VENT HEATER - ..•Y I- - 1_ . ..1 , ry.1 I, 1• . ..,j• • ` ,.. 1• ' • -_I 11_ .. I rt ••:I DRYER ,.,...,-....1 _„,/<_ ...�.�::......,..,i . I . ._,1_ -.I f . . .f1.... ..µ.i ._._ .ff_____;1,,._:„:! • FIREPLACE _._ - I' _` . ..`.f «,.. .:I ._:, _.,_„1.. _-I__A : _..1�......I ,I _il...,.1..( —_ FRYOLATOR ._ III— _; F....._I _. . ( .fr.,__ 1 - . _. l.,. 1L....,. , ...,i ..--i __ II,._._..11:'. •F • FURNACE I. ' _., ,I �, �. 1 _.._•<II- 1 GENERATOR -,...-1:.�_.. =1 -_ ;3 . ` . I t.:_= r GRILLE • .. , 1' ,i,..-t.. 1 .. . ...... II< . . 11,= ;1.= .1..,<, I., ._. • • INFRARED HEATER 'I : . _:;I._.. _1 I ,i . II. T I_ ...,. 1 r1,,, _ . . _ P ..1 ... LABORATORY COCKS . w.� . 1 11«,- ,1. _..1l• I _..• ...1. .f _ . •, . 1 I r m 1-. MAKEUP AIR UNIT _�_ .. I i _OVEN • .4 _.. ;....• I 1 ...�_1 < • tI. _._r , _ ..�1 .._...I _.Dl �._„ �f _•-__F.. ._1_. Tf<,< t -�.J .:.,..�,_�.-:I -•..,, . _I .�-.. ._„,..., .. . .l• 1.,„•,--1 p00LHEAtER -�- � -r- ��• �- � - ROOM/SPACE HEATER ... I <..-- '_.••t,,_,,.•_j',,,_:_jr.,,.., _. _a-,....... ..` ., .._. _>.___,I . ..-_;...... __ ROOF TOP UNIT I ,r,_.f �. ._ 1 �..�a�, • 1_... .f F j ' I t_ T..... I UNIT HEATER - ' i.__-• + ( � �FT�_ . ..... _{ .1�—�, ..- •-.�I -.,} UNVENTED ROOM HEATER _1 .. <.. _i....,,....i n i -_ _-_.., ..r„ _r._.1 ....... .. -= -••- - .: - WATER HEATE II ' , .-.1 ---1......-.,F..... __i__A ._.- ._,J= .-._ �-- -•i I.- . 1, :.,1 -1 Q5 L I h f =' ,.(.,.. .. ....-F --_.. :vi- _f I ._ ...1. .-<1 ,.__ ,.•_,i.._ „ 1. ._. ..I _ ._ 4 :- , • ,1 ... .1 _._.._. i . ..i r .. ._fI�__:._I .. 1. 1 ... I__�.____1.w. ,_...I .. .-.I _._.,I , ...il: -- INSURANC)`COVERAGE I have a current liability insurance policy or its substantial equivaldnt which meets the requirements of MGL,Ch.142 YES 1 NO ,.I I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY :,_1'_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 ,.,_. 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 d 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 comp ce with all Pertinent pro sloe of the Massachusetts State Plumbing Code and.Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME: STEPHENN A WI[ SLOW LICENSE41,1229, , s• SIGNATURE MP:.K'XMGFL# JP .,_i JGF .j LPG!., , CORPORATION 1-a#13281C 1 PARTNERSHIP ._'•#.,•,,, , f JIGI41 _... COMPANY NAME: E,F,WiNSLOW PLUMBING&HEATING I ADDRESS',8 REARDON CIRCLE .- CITY SOUTH YARMOUTH i STATE: MA P ZIP i 02664 _ITEL 508,394:7778 ••_ _ •• , • ,•_,G FAXI SO8 39d8256 1 CELL. ;EMAIL:AGCOUNTSPAYABLi @l FWINSLOWCOM •, _.. .1 a. 1.1..- The Commonwealth of Massachusetts _Department of industrialAccidentis T., ,,,, ‘,7,,,, f Y� Office ofIlnvestigations " �f�-- ; 1 Congress Street, Suite 100 . .[' �< Boston,]L1A 02114 40.17 .o'4 VOBc `O www mas&agov/dia .� Workers'Compensationn Insurance Affidavit: tr uillders/wont)rectums/Eleetrrielans/Numbe g A licant Information Please Print int Le ibl Hanle(Business/Oxganization/Iridividual): E. F. VVINSL4W PLUMBING & HEADING CC.,INC. .dd_ress:8 REARDON CRCLE amity/State/Zip:SOUTH YARMOU T H, MA 02664 phone508,394-7778 ppro re you an employer?Check the appropriate box: #: p 12 I am a employer with 70 4. n I am a general contractor and I Type of project(required): employees (full and/or pare e * have hired the sub-contractors 6 U New construction I am a sole proprietor or partner- listed on the attached sheet. 7. U Remodeling shill and have no employees These sub-contractors have V3� 8. Demolition working for me in any capacity. employees and have workers' . [No workers' comp.insurance comp.insurance.? 9 n Building addition 1"required.] 5. U We are a corporation and-its 10.E Electrical repairs or additions 1 am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL 11'_n Plumbing repairs or additions insurance required.] t c. 152, §1(4),and we have no 12. Roof repairs • employees. [No workers' 13.[ Other comp.insurance required.] applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. eowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. actors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have tees. If the sub-contractors have employees,they must provide their workers'comp.policy number. an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site nation. snce Company Name:ARROW MUTUAL INSURANCE COMPANY '#or Self-ins.Lie.#: 1794 A 01/01/2016 `• Expiration Date: • to Address: J ) )tit _ _ City/State/Zip: /ifri p i!i i f� , �JLP&L f n a copy of the workers' compensation policy declaration page(showing the policy number a d expiration date). /l{ s to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a 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 )$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of rations of e 151.kfnr insur e verage ve' ca j n. • weby certify under pains dpenaltiesL /. f,:eryury that the information provided above is true and correct. re: - 2016 Date: 508-394-777g ial use only. Do not write in this area,to be completed by ci0 or town official. • it Town: Permit/License g Authority(circle one): ird of!:,ealth 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector er et Person: Phone 4: