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HomeMy WebLinkAboutBLDG-20-001486 -b • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _- c 2, T i->' CITY YGffilf tlty_ .. ... ._.-._._. _ MA DATE__61Ij.2.j11.._ 'PERMIT#/AO'go / r( JOBSITE ADDRESS , i,ff_ XV1.4 .Q • f/yj NAPb� .._OWNER'S NAME G OWNER ADDRESS .3.LC( d_eSdaje-Dl._ Ptf' f,eW MA 0I/01.TEL,y(63yq 5/5 - ..FAXI_----_____-.. TYPEOR TYPE COMMERCIAL[] EDUCATIONAL El RESIDENTIAL[ CLEARLY NEW:D RENOVATION:® REPLACEMENT:0-------- PLANS SUBMITTED: YES[-- NO[] APPLIANCES 1- FLOORS-- imp 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER WM AM I_ - -1 - mum.--_. ___._� CONVERSION BURNER M � , BOOSTER COOK ST VE ....E Mali___ ._.. NM MI MOM MI ` C_ DIRECT VENT HEATER - - DRYER . . . . . . . - -I NEMM NM MI S I®i il_ FIREPLA E r[aang,ER NSW GENERATOR — ,i j I� L i— (--L.-.. i FURNACE � � . .._ I� _!_•, Jam GRILLE 1 - -- -- ---H.-itirmont=__ _..:riorl INFRARED HEATER ��i ,... LABORATORY COCKS ice« Ali MAKEUP AIR UNIT - OVEN ;« lll�Ii l �l,'I I II®il—_ ' II _I POOL EATER ROOMH SPACE HEATER L wji�i � I _ l i - RCSOFTOP11N11`----------------'r MEN TEST ' ,MI UNIT HEATER NEi _._ 110141111110 1 UNVENTED ROOM HEATER ��I�"r ._. _ i� nj WATER HEA -, TER I . I OTHER W.I I MR om� ��® . ...._ _. _•� .'� m�iL11��J� '' _ ..." _._._ � I ®�1�� 11 hII--- - - ... .---. . . ...._.__. ..l- _ I l! )� ®I emmenw Jmi INSURANCE COVERAGE - I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES rilNO i IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 21 OTHER TYPE INDEMNITY 0 BOND D 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 Q - SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and Information 1 have submitted or entered regarding this application are t 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 co • nce with all Pertinent provision of the . Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i L.�'�! M PLUMBER GASFITTER NAME STEPHEN A.WINSLOW .LICENSE# 12298- SIGNATURE w N MP E MGF 0 JP© JGF D LPGI 0 CORPORATION I# ?MC_- _ PARTNERSHIP D# , _ - : LLC 0#_ -,_ _ 1 s_ A- V) COMPANY NAME: EF WINSLOW PLUMBING&HEATING ,ADDRESS 8 REAiZDON CIRCLE• • __ CITY (SOUTH Y 1Rl1Ql1TH, . ... -. __,.__ -.__ ___.I STATE MA~'ZIP 02664_ - _TEL 508-394-7778 '/ FAX 508-394-8258 1 CELL N/A .. .EMAiL�accountspayable@ef�iinslow.com _________:___._1 4 L The Commonwealth of Massachusetts 1Department of Industrial Accidents �t—t c jitilM 1 Congress Street,Suite 100 ,,M-t= ,t, Boston,MA 02114-2017 �` www mass.gov/dia �SSV- Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH filt,PERMITTING AUTHORITY. Please Print Legibly Applicant 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): 1.0 I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 9 0 Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 D Building addition 4.EI I 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.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.Q 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. $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.#: 1909A Expiration Date:01/01/2020 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 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 of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ND I do hereby certify and a paiind pen lties of perjury that the information provided above is true and correct. a Date: r Signature: -....�� Phone#:508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. Permit/License# V City or Town: `1 1A-.. Issuing Authority(circle one): �/ 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other I, Contact Person: Phone#: