BLDP-20-004662 (2) 1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�lif- ` CITY YARMOUTH_.__....._........._..__...........___..__....................................`..._........................_...._._..1 MA DATE 2-20-20 PERMIT# 44/5 `� yt1Qa
JOBSITE ADDRESS 364 FOREST ROAD OWNER'S NAME CLAIRE HOWARD
GOWNER ADDRESS 364 FOREST ROAD-WEST YARMOUTH TE 508 398 1611 FAX ,_
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL LI RESIDENTIAL Li
PRINT
CLEARLY NEW:Li
RENOVATION:Li REPLACEMENT:LI PLANS SUBMITTED: YES Ej NO LI
APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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INFRARED HEATER lint 1111111M1.11111.11111111111010111111.1.010.IF1111110111
LABORATORY COCKSall INK;'NIIIIIIIIIIIIIIIIIIII MI IIIIIIIIIIIIII MN MK.NMI 111.111111.111111 Mk
MAKEUP AIR UNIT 11111111.1111.1.111 IIIIIIIIIIII1M11lMnlijlig,MTMWIOM
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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 0 NO LI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY CD OTHER TYPE INDEMNITY Li BOND
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 0 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 accurat to the b st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliancncaJY'P/�ertine provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 71 • ` -
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PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE#112298 SIGNATURE
MP El MGF® JP LI
JGF Ej LPGI . CORPORATION Li:# 3281C PARTNERSHIP #� I LLC u#
COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE i
CITY SOUTH YARMOUTH STATE 't.,1/11 ZIP 102664 TEL 1508-398-7778
FAX F508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM
The Commonwealth of Massachusetts
Department of Industrial Accidents
-ra'ig►= G Office of Investigations
Lafayette City Center
2Avenue de Lafayette, Boston,MA 02111-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 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: Business Type(required):
1.111 I am a employer with 90 employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.9 I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl. real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp. insurance required]** 11.0 Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.El Other
*My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. #1909A Expiration Date:01/01/2021
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under§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
the DIA for insurance coverage verification.
I do hereby�� the penalties of perjury that the information provided above is true and correct.
Signature: Y Date: 01/02/2020
Phone#: 508-394-7778
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(check one):
1fBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.El Licensing Board
50 Selectmen's Office 6.DOther
Contact Person: Phone#:
www.mass.gov/dia