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HomeMy WebLinkAboutBLDF-16-001407 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK n '' CITY _�y{�-k. ((YT 1 MA DATE CI\ I ifs PERMIT# r1(9 6'0? JOBSITE ADDRESS ?} • l oec.. r1.L`,4.— ,, I OWNER'S NAME !— LLc YPw- G -OWNER ADDRESS C9:r i(1L T' ~ 8.(ISO, 1FAX ,. TYPE OR OCCUPANCY TYPE COMMERCIAL .....d EDUCATIONAL _1 RESIDENTIAL PRINT CLEARLY NEW:_....1 RENOVATION: _i REPLACEMENT:> : PLANS SUBMITTED: YES _I NO _ APPLIANCES'I FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I__I� I .1 _1 _ -.. , -- ,-- -__1 BOOSTER ......,.....J,,_ _._._.j 1 _1 . , , 1._ ._,_1 P_ .. ...i� CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _ 1 _....... '___....j _ __I .1 . ._. ___I_ I__..... _ . ....____.I' J... .._I DRYER __ J___J _... I_ I __,_.J _.,,. ._1_,.,. __ I .__._._I __! _a J ._._. I FIREPLACE 1 I! _J______J _.�___I i 1-_-___i ' I i 1 -_i I FRYOLATOR _ .I J:_ .J _..,... J... _... __J.._ ...._._I'_. J I FURNACE 1 _ IJ 1 1 I I__ I 1 i' 's I GENERATOR _ _. 1__I__J- ..J___i___I J I____II _J ____i I I GRILLE __ '_. __ _ I 1 _ I I Y I _ I INFRARED HEATER t $: I I l_ ) I 1 _._,,_ .. I _I LABORATORY COCKS _ „ ,wJ __ L. i I__. J__..._. .._...I. _I s. _ .. __I _M_,.J MAKEUP AIR UNIT ._ _...i _....w..: i___I..._........I___I_. __I_.I __.v__ I____I„...1 J__ .1__I OVEN ,.....�..I .i_�..._.J.,.�..... ___I _.J_„_1 a w._ _.._...,I POOL HEATER I___I'- , I I 1- 1_._.._.._.1._.._.._.1.__.._I I I I__I____I ROOM I SPACE HEATER ___I ...,_,J`. $ I,_... I,__I _._I__I,.... !.,,,..„._1_..... ....I .I___I ROOF TOP UNIT wl...._v..1 _1=.-.......I'`..._ _.. ..._._1 I_,I _...__I�..,_�.J_....._.1 l- 1.._...... TEST 1 1'_ _.:.n....- I...__._a `.. ...... ,....._,�,J ..I........v.w1,�.... t.�......I„ ,.w-�.,-I NIT HEATER , _ __ I I. _ I' 1 1 ___I. _n � I _I NVEN ED ROOM HEATER I J ___, _ . _ .b___ ____.J __I_...m..._? .. .....I ,__I _1 I _,..,. .,,1._r, l I1 _I T R I � {� I i 1 r-, r i. .. 1,� i ,,... .I i'___I _ I J <r. INSURANCE COVERAGE I .. _.m_.,... _x ........... 1 _ W , I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES `1 NO _, I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY X. 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 ...J AGENT ._...,' SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application ar and accurate best of my k wledge and that all plumbing work and installations performed under the permit issued for this application will be in co 'ance wi all Pert' ent provision the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A WINSLOW I �2298 ,LICENSE# S ATURE .. MP LXIXMGF _I JP ,J JGF __ LPGI ._I CORPORATION# 3281C PARTNERSHIP # LLC ,_.:# F COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE mMA_ ZIP 02664 _ TEL 508-394-7778 7778 _ __ FAX 508-394-8256 1 CELL m _w _mm EMAIL ACCOUNTSPAYABLE©EFWINSLOW COM _ w1 The Commonwealth of Massachusetts Department of I( js ?al Accidents =;? � l Office of Investigations n_ � 1 Congress Street, Suite 100 =4�1= Boston,MA 02114-2017 •''ai- www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly • 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.El I am a employer with 70 4• 0 I am a general contractor and I employees(full 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' comp insurance.x 9. El Building addition [No workers' comp. insurance p 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.1=I Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.1=1 Other comp. insurance required.] 'Any applicant that checks box NI 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 r P IA o uranc, co erage veri jtion. I do hereby certify un' e s and 'enalties ferjury that the information provided above is true and correct. ,L 2016 : ivaDat • 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: '"1hone#: