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HomeMy WebLinkAboutBLDG-20-000666 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _vm 9 CITY _YA 1.d_a-1- ____ . ..._.._.___... •..__: MA DATE,_.9)12.//.q. PERMIT#l,17 QD`OotoOa& JOB ITE DDRESS .JI D_.CAPhia, //last G ..Kd,,,. .. OWNERS NAME n . • (2to. OIQ/NER�DDRESS .�1 (lll� eLli,Cid-_RI.beD iAifri Ir1]k.TEL yDS-Sa4.a31 a..FAX I--____----_ . u 14 TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL 0 RESIDENTIAL[ PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT:Q' PLANS SUBMITTED: YESID. NO APPLIANCES-1 FLOORS-+ BSM 1 2 3 4 s 6 7 8 9 10 11 12 13 14 BOILER . n I._. _. - .. ...._.... . - '. BOOSTER I_.- I FT IlialI _. __._ ._..- CI . • . .- __I_- - F ____ CONVERSION BURNER COOK STOVE L_ ._ _._. I l .--_- _.._., _ -.._ ..'_.,.__.1 .. _(._._- .__IL.....C-IC_......I DIRECT VENT HEATER L --L_-:_I____{. . ..._11_1.._._IIL---....I._. .__I_._ .I....-_.._IL_...-.1----- -'II_ I DRYER FIREPLACE I___'I..._..."I_..._.1...._..:L_1_- -:-1 -.... i..._-.' ._ ... .. . .. -_-_ .. ._.1 .---- - FRYOLATOR ..--tE- -1L11 r ,,.. .-.- l_�,- -..I ..-.._„ ...... ..... .i'.... ._.� _ _ .11 i. ..II.. . . I FURNACE �f 3I I I_ 1 __I1-11--1___._r ..I,(.•.. :1 GENERATOR - I ..... -Iiii. AIM ME- 1 11111111 1-_.. I II..._....I GINFRARED HEATER ' .ji--...._.IT.. .�. 1 . -_-. 1 �J - - - --- - L-__--11—_, LABORATORY COCKS 1._..-, .._ _ _ .. -;._ . .. ..-.I j . ...J _=.�,d ._:1 .. . .Ill. .... 1 MAKEUP AIR UNIT _ [ ].,� ,_,1,. ... -_--_I ,.L 1 OVEN _ ; POOL HEATER I ..,._.. . --`L- 1 ROOM!SPACE HEATER i '' I._;-_:i._-_.1I ...11 _..._1 Rt7OFT0Fr UNIT-----------------1 TEST -. •._ _ --- UNIT HEATEfT UNVENTED ROOM HEATER MI _. _;'I... y: - - WATER HEATER i'_._ I I .. -. .. . OTHER —_. _y ®I.. . .- . - pm --_J — _ _ _J® ._.... ... ..:mompoI _:-._1...__I ..--11_ ....L., 1.._.... _- :.uli _..,.... . __. .,'L...__.). _.. =f-.. ; . _. . L..___,..,1.. ._ L i-__--1L._._IC .=1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES rii NO [ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY[+_. OTHER TYPE iNDEMMNITY E] BOND 0 •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. O - CHECK ONE ONLY: OWNER ID AGENT 0 . 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 ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compile r with all Pertinent provision of the t`fJ ;Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME STEPHEN A.WINSLOW .LICENSE# 12298 SIGNATURE ,TO MP ID MGF0 JP© JGFQ LPGI 0 CORPORATIONQ# 3281C PARTNERSHIP0# : LLC Olt_ _ COMPANY NAMEI EF WINSLOW PLUMBING&HEATING, ,ADDRESS 8 REARDON CIRCLE • CITY SOUTH YARMOUTH . .., s. -..- _._,_,..,1___,..,1 STATE I MA, 141Di 02664._ _ , .TEL 508:394-7778 _ FAX 508-394-8256 CELL NIA .• :EMAIL accountspayable@efwinslow.com • i The Commonwealth of Massachusetts G Department of Industrial Accidents "—yeliniff t 1 Congress Street,Suite 100 Boston,MA 02114-2017 • %b— www.mass.gov/dia • Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.•. '1'0 BE FILED WITH rHL' PERMITTING'AUTHORITY. J Please Print LegiblyApplicant Information Name (Business/Organization/Individual):E.F.WINSLOW PLUMBING &HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): P y ---- .m } s full and/or part-time).* 7. New construction L�✓ I am a employer er with-SS p oycc ( p ) \ 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. �]Remodeling A\VI�'1 any capacity.[No workers'comp.insurance required.] 9. []Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]I. 10 Q Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 11 []Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance t 14.❑Other 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no 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. IContractors 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. ARROW MUTUAL INSURANCE COMPANY Insurance Company Name: Policy#or Self-ins.Lic.#: 1909A Expiration Date:01/01/2020 City/State/Zip: Job Site Address: _ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). :4\ Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofdedf at STOP e OfficWORK OORof mORDER ioand of the fine of forup to$250.00 a day against the violator.A copy of this statement may be forty coverage verification. I do hereby certify and a pai s nd pen (ties of perjury t that the information provided above is true and correct. .,A 9\ Signature: �° �1„f, Date: '.,�....a Phone#:508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. Q City or Town: Permit/License# 1 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#: