HomeMy WebLinkAboutBLDG-19-006719 .if . M • SACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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/ I Aga MA DATE a6'67/4 IT#appAP o0 0 Ze e
JOBSITE ADDRESS..3 j i p OWNER'S NAME /./ a/d72-.- 1
G OWNER ADDRESS /a4 iv!IZ/7Af /_Jll� 1 TEL ,/ I.1 (Jii FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL'J EDUCATIONAL I RESIDENTIAL
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CLEARLY NEW: I RENOVATION: ,f,....i REPLACEMENT: PLANS SUBMITTED: YES ,.,_,j NOLL
%\ APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
N. BOILER , , I` .- _ m 1 a. L _J, �1 L...........4_,J._
BOOSTER I....w,,J I I .
<3 COOK CONVERSION BURNER . a' _____I J .. _ 1 ____
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STOVDIRECT VENT HEATER — ..,... ..1_____,1 __,..._.1. _..__ ..._.._,I _1 ..._....._I _1.. ..____._1_. 1._ _I I ___
DRYER ._ I _..__..J_._J'___.1 1 I _. 1 _ i__ .1 __.i .. ._..I....... I I
FIREPLACE _ I_ _ _1 . ,'__� J _J*_._.. __._J_ 1 J ___I J_-_.J I I._ i
FRYOLATOR _J 1 _ 1. i_.._.._.I I _,... 1_. .......J . .I l .i._._._J
FURNACE
GENERATOR J I I . . _w...____I__. I 1. ._ .. .1 1Mµ
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GRILLE _ ._:__ .1 ri: _._...
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INFRARED HEATER _ .J. ..__I . ._J 1___.....J! I 1 I___,._J I__....... . .I.__I
LABORATORY COCKS ._.1____d1 _ . __. J__.—..1-._..___.1
MAKEUP AIR UNIT I_. _.
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_1 I .._ II_____1® I__.. .____
OVEN s ___ . = 1.......nJ A_�'.._..__I _...___1 _ 1 �._..._1 . ___—_1 ..._..I_____I M_...__ ____1
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Cd POOL HEATER .1,_... - _J_ I........_.J '' I._,._.,.1.,___J., ..�.J I _I___.__ _J
ROOM/SPACE HEATER J.. I,.. ,j...___I' I^_._-._J J _ I_ I .,.._...J ___I I_.., _ _i,____I___J
..0(4_, ROOF TOP UNIT I I` '_J._ _.J I._ ! __..I j 1 ...._.J, ; .._...h._,__._I_._I
TEST 1____J .:'_.....,.I._ ,... ,.____I _ Y...____I___I__._I;... J _: I___1,,___,_I_____1
UNIT HEATER __.....f__.....,._1____ __I _I.._. I
UNVENTED ROOM HEATER ..... _ ..,.,.j _ ....,. .....__J J,____. .._. I ..!_____I _L ,.w. . ..__ __J___I
WATER HEATER _J_I _,__,I._,.....,I, j;.. I r...._....J,. _... _i___.J.,_._,.,
OTHER 1 . ..__.1......._I .__, .•1 .4..„___I_ __I __I .,.. ____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 1+ i NO IJ
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY .._J,.1 OTHER TYPE INDEMNITY rteBOND 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 ._,...1 AGENT .
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 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 complianc 'th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
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PLUMBER-GASFITTER NAME STEPHEN A WINSLOW _ LICENSE#'.122.88._1 SIGNA UR �M�
MP'._'„i)(MGF .,,,..J JP _,J JGF __w LPG! __' CORPORATION +1# 3281C PARTNERSHIP ...... # 1 LLC "#_ j
COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING j ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH __ _ __ _..,r__ STATE _MA i ZIP 02664 _ _ ;TEL 508-394-77_78 , w ____ . '
FAX_508-394-8256 1 CELL_ J EMAIL ACCOUNTSPAYABLEIEFWINSLOW.COM _ m
The Commonwealth of Massachusetts •
DepartmeruteIndustrial Accidents .
_=17.111=-77.Nig .• Office of Investigations
t. �. , 1 Congress Street, Suite 100
r
Boston,MA 02114-2017
'``'.'"' www mass gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
•
Name (Business/organization/Individual): E. F. WINSLOW PLUMBING & HEATING CO.,INC.
Address:8 REARDON CRCLE
City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-3944778 .
Are you an employer? Check the appropriate box:
Type of project(required):
1.12 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
2,0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
insurance.t 9. ❑Building addition
comp.[No workers' comp. insurance
required.] 5. 0 We are a corporation and its 10.0 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
12.0 Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
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. #: 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 t 5I odor nr surance'co erage veri•• •tion.
I do hereby cert f un e s and enalties 1 ,erjury that the information provided above is true and correct
/,-- 2016
Signature: \ el Date:
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: '� 't'hone#: