HomeMy WebLinkAboutBLDG-17-006527 ,.. MASSACHUSETTS UNIFORM APPLICATION FOR A P Writ tir i ORM GAS FITTING WORK
:• G' CITY / i1f / Ii ___ = _- MA D'‘ U • / •/7 0 IT# &1, /7 Gb
JOBSITE ADDRESS .1 �� ► ER'S NAM ,/ igfQ-i--/
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G OWNER ADDRESS Yt/ i it .. clU' T FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL® RESIDENTIAL
PRINT
CLEARLY NEW:ED RENOVATION:Ed REPLACEMENT:0 PLANS SUBMITTED: YESED NO k'''.
-.' APPLIANCES 1 FLOORS-► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOILER ' -I
BOOSTER ,������_ ����_ ��,-- � . k
CONVERSION BURNER i t . .,'1 _._t _.. t - _-- _ .
1 COOK STOVE !`_ -; _..—i . r-,` __ I � - .` 1 .I r -- :!
DIRECT VENT HEATER (_� ' i 5 i
DRYER ?' —11.Th -.. 'E: . • -t __ __ - I=_ _ I
FIREPLACE _ •
FRYOLATOR I ...:-1 -1. - i l 1
FURNACE it ` ""'' ' _... . r 1= _ .f+ f'. I� .
_GENERATOR •
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_GRILLE ( I;. . ' i _ I II.
INFRARED HEATER :W ' .. _ `
ORATORY COCKS • — — _ .__ .
LAB
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MAKEUP AIR UNIT I _ i.1 _• _i — — — ' .I _
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POOL HEATER �' � �
OVEN
ROOM I SPACE HEATER _ �_ �� -"
ROOF TOP UNIT
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TEST ., ' .. .:.�.:..._._.s---� � -'
UNIT HEATER 1 _ _ lmi
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UNVENTED Re,; HEATER � ��+���l��i� ,_--
WATER � i { _ ,
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INSURANCE COVERAGE
I have a current liability insurance policy-or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E; OTHER TYPE INDEMNITY ( 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.
CHECK ONE ONLY: OWNER ® AGENT 0
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 and urate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance all Pertinent provision of the_
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I STEPHEN A.WINSLOW I LICENSE# 12298 SIGNATURE
MP Ell MGF Ei JP 0 JGF D LPG!® CORPORATION E.#[3281 C 1 PARTNERSHIP 0#1 !LLC 0#.1111111
COMPANY NAME• EF WINSLOW PLUMBING&HEATING `ADDRESS L8 REARDON CIRCLE
CITY SOUTH YARMOUTH 11 STATE MA 1 ZIP 02664 ITEL 508-394-7778
FAX 508-394-8256 CELL N/A I:EMAIL accountspayable@efwinslow.com __,I
Department of Industrial Accl!aenzs
I' - _ Office of Investigations
:1v'= . 600 Washington Street
t,_ "
Boston,MA 02111 •
�,_. t; www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please� Print Legibly •
•
Name(Business/Organ ization/Individual): E'c•w,,5 t ov, QtV„^'�6�`' cj 1. 0 a� (`e) t
Address: aR crawl C tip'— .
City/State/Zip: Soo %'\ +�"o'.' t` Pc Phone#: `SUS- 31:14-1/717S3 •
Are you an employer?Check the appropriate box: Type of project(required):
I am a employer with '70 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors# ❑Remodeling
1..ElI am a sole proprietor or partner- listed on the attached sheet
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. _ workers' comp.insurance. 9. 0 Building addition
-
[No workers'comp.insurance 5. We are a corporation and its 10.0Electrical repairs or additions
required.] officers have exercised their
1.0 I am.a homeowner doing all work rightexemptionper of§ MGL 11.❑Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
im an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation.
isurance Company Name: PP YD•• rk`l OA ,,LiqurCk6 U.- ` a "'6� •
olicy#or Self-ins.Lie.#: r ' a 1 A' • Expiration Date: t—( - adn
)b Site Address: 3 CO/vv.-kw')w-ea-111 N Adel C 1A1`‘ City/State/Zip: (5,)1-1 to?
.ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). .
ailure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
tie 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
f up to$250.00 a da a:ainst the violator. Be advised t,at a copy of this statement may be forwarded to the Office of
tvestigations ' the DIA for insurat�eeloverage veri a on. i
do hereby cent j un'• e ains and penalties o pe jury that the information provided above is true and correct. c'
i• atu3-: o -""" 4 r.. .�_ Date: ( - i a01(
hone#: .S7)I,•..cl`i- 777g (J
Official use only. Do not write in this area,to be completed by city.or town official • .. .%
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 v
6.Other
Contact Person: Phone#: • A