HomeMy WebLinkAboutBLDG-18-005481 i' * MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS 53 ///S Lei re/--e (OWNER'S NAME &..-,c/A,.¢ j%/,4. 1
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CLEARLY NEW:Ei RENOVATION:[6] REPLACEMENT: PLANS SUBMITTED: YES® NO PI
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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 [NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY El, 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 D
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are 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 corn nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
- . p,� ix�
PLUMBER-GASFITTER NAME 1 STEPHEN A.WINSLOW I LICENSE# 12298 -' SIGNATURE
MP Er 1 MGF D JP D JGF D LPGI El CORPORATION E# 3281C a PARTNERSHIP D# i LLC D#1 1
COMPANY NAME: EF WINSLOW PLUMBING&HEATING 'ADDRESS 8 REARDON CIRCLE 1
CITY SOUTH YARMOUTH STATE L MA ZIP 02664 ITEL 508-394-7778
FAXI508-394-8256 .,CELLI N/A 1 EMAIL accounts'a able.mefwinslow.com '
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Department of Industrial Aicctaents
t'-..rw`'�`/ Office of Investigations
=:.1t1I= 600 Washington Street
G -1 1 9 .may
Boston,MA 02111
i _ www mass gov/dia •
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
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Applicant Information
Legibly •
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Name(Business/Organization/Individual): e'c•W�•'�5�O..l kAklO t✓AeL �{.a- � c�-} I t
Address: � (Pcsn (."‘t(OLP.— • (j
City/State/Zip: So.)ki•N +^^G-'4" MP Phone#: 5s-Y9kt-1T7S1 •
Are you an employer?Check the appropriate box: Type of project(required):
I am a employer with 70 4. 0 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
;.0 I am a sole proprietor or partner- ❑Remodeling
listed on the attached sheet.#ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its 10.1:Electrical repairs or additions
required.] officers have exercised their
11. Plumbing repairs or additions
I.0 I am a homeowner doing all work right of exemption per MGL ❑
c. 152,§1(4),and we have no 12.0 Roof repairs
myself.[No workers comp. . o workers'
to
insurance required.]t employees.Yees13.0 Other
comp.insurance required.]
1ny 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.
"dm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Tormdtion.
isurance Company Name: i�lY�D `� � S 'n 02- C �4'1
olicy#or Self-ins.Lic.#: r
$a l Expiration Date: t H an i
M�\e O14h �I ON2 Al\I City/State/Zip: O 4 b 7
)1)Site Address: .�
.ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). •
allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
ne 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
Nip to$250.00 a da a:ainst the violator. Be advised t i:t a copy of this statement may be forwarded to the Office of
•
ivestigations • the DIA for insurer- ,overage veriii on. I
do hereby certify un'• •e airs an;penalties o jury that the information provided above is true and correct.
�ti.,, . _. Date: (off. i aoO
i_ atu�i=' ! —
hone#: . 5,•35H- 7 77X
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#: