HomeMy WebLinkAboutBLDG-16-001328 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
I CITY V 4y m p tit f- MA DATE PERMIT# 1-0h. -Cy l
JOBSITE ADDRESS OWNER'S NAME de.5'
GOWNER ADDRESS ✓y24`1/1 J 11/F TEL67J ��4Via-f ,/( _I FAX 1
TYPE OR -
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OCCUPANCY TYPE COMMERCIAL �,I EDUCATIONAL RESIDENTIAL ,_.
vo CLEARLY NEW:__I RENOVATION:,_ REPLACEMENT: a�Y PLANS SUBMITTED: YES,.j NCY.,
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER - ~� , 1 I.� -, , I. i' „I ,. —.1
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0 �CONVERSION BURNER �.,�_ 'e_____I ..�.... 11. .._..,.1� � '_._..�..I -� �..�I �.�. .. ___I.�..<.��_.�w
COOK STOVE
DIRECT VENT HEATER _._._.?J . i___I` _ 1 1 ___._,.1.... J°:_.,.__. _ ,_ .I __J 1 n.. J t_ 1
DRYER .........._. .w....__ _-,._.J'. ....1 1 1 1 ...._. '............1 ____1._ 1 i._,._ ____
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FIREPLACE ,
'S FRYOLATOR 1.�._... ____ ___1 .-_. 1 ..-..- -I-� 1__....r _- 1 1 I, 1 1'_1 1
J FURNACE ; ._ 1 I 1 1 _.._.__1_ 1 . . 1... .....1 I ,€ I I I
GENERATOR ____I 1 1___,1_.. ;. .__ 1 J.__I__ I. . 1 _ 1 J 1 1 ___J
GRILLE __...,_ ._._._._ 1___1 1 1____ 1; I 1 I ._._..J 1 1 i 1
INFRARED HEATER J J _1 i s 1 1 L. 1-.,..._._, 1 1 .1 1. 1 __1 I
.LABORATORY COCKS ......_. _...m1, 1,-. 1 1.m..-..J_. _....1..... _ .a __I______I___. ___.. _...__.1
MAKEUP AIR UNIT 1 . ...1 I _.....�..1 ____1.. .J _1..m.,_ I.
OVEN ..,_ ...1 ___.l..®__..._.1____1 m__1 __.J___.1 _____I .__.. .w�_I___1 __I„ J _. _.1
POOL HEATER .�_..J _.._I 1____I I 1 . 1___1 __�.J• ..J I I___(___I
ROOM/SPACE HEATER 1T�....._1', I':_.._.1'__.._1'___ _ 1 - 1_ 1'_., ..,. _.....-.i'. . . I _._..._1
ROOF TOP UNIT 1 ,� _J J_ J°_.1 _.1,_J , I__-___I_. _. .
TEST ___I___1 1 -.____1,_ __.1 I_1 1, , ___1 _ I.F.. ...I,,_____I:. I
UNIT HEATER I. 1_ .. *„..1 ,.�..._....1._..._...W_ m_-.,_1 ............3 I _.._ 1_1-1 d {
UNVENTED ROOM HEATER __.....J _.�1_.__I € J',. ,,._i 1, _...I�.. ,..,,�1.... ..,,..1.w.. ._J,___1_ _I
W TER HEATER f _____1. a _. .,._ :,. I__J�..�,a G___j . ; -
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INSURANCE COVERAGE
I have a current li i it4insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ILi!NO
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 I _
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 '_._1
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 nd 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 compr ce with all Pertinent provision of th
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 6//
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW j LICENSE#i2298l SIGNATURE
MP . 3XMGF __1 JP __,1 JGF n_= LPG! _1 CORPORATION /.1# 3281C PARTNERSHIP ... # LLC _..,#'_
COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING i ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 !TEL 508-394 7778 y
FAX 508-394-88256_ J CELL, ;EMAIL ACCOUNTSPAYABLE EFWINSLOW COM ___ _,..._-. ..-_1
to
The Commonwealth of Massachusetts
Department of I# ' s1 it Accidents
;'>i�_�l 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
employees(MI and/or part-time).* have hired the sub-contractors 6. El New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. El Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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 13.0 Other
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.
:Contractors 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
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 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 IA o ' uranc co erage ver c tion.
I do hereby certf un a and enalties erjury that the information provided above is true and correct.
,�, 2016
Signature: Date:
Phone#: 508-394-777
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#: