HomeMy WebLinkAboutBLDG-17-005437 IIP ASSACH'i=iiS`ai S UNDFCRIIII Mr.Pq 1CAa'lOAI FOR,AI (liii;l,0 P,ERFCRlfilZAS 7177%.0 WOIv"s1;
CITY r MA DATE .2•r..1 .7
,w.. .. ... PERMIT#
JOBSITE ADDRESS
....I.r5c-.1-.jN:..CY Qci.. _ _R..__._._....OWNERS NAME y_,SC�i.C( '�!'� I ' LC'r,
GOWNER ADDRESS ., :C`5 �;uC..- ...( .i..11fJ7 w1l� TEL -J,ISa.FAX .:._........_........ .. ..:
TYPE OR OCCUPANCY TYPE COMMERCIALEDUCATIONAL ._i RESIDENTIAL&
PRINT .„
CLEARLY NEW:__1 RENOVATION::.,.. REPLACEMENT: G:--- PLANS SUBMITTED: YES NOL„,:
APPLIANCES 1. FLOORS-1. BSM 1 2 3 4 5 6 7 8 9 10. 11 12 13 14
BOILER _......_.
• 4
BOOSTER
.1• ` _ _ ...
CONVERSION BURNERM.. .._.._.._ �...._ _........ ...._..._
COOK STOVE .M ._ w.. .�.....: J
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DIRECT VENT HEATER -_�_ .. ..... .. -: ."_.. ' . _ n_
DRYER
FIREPLACE _ �., . y ', r. •.,.,� '..
FRYOLATOR F . . �.,�......_
FURNACE .. -,_,...__,. r M ..
GENERATOR
GRILLE
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INFRARED HEATER
LABORATORY COCKS =._...... -._ ._.... ..._.._.. _._- • : __.__._ .__......_
MAKEUP AIR UNIT t .......,s ._.._._._
OVEN
POOL HEATER • , --
ROOM/SPACE HEATER - - .. ' '
ROOF TOP UNIT w.w . .�...w!x x_ �..• _.
TEST __. ___ _ __ '
UNIT HEATER
UNVENTED ROOM HEATER
WATERHEATER..._._.._.._..._.....__................ ._..._� ' �.�_. _ w` _,
OTHER _ ^µ ; I r _., r .. . { . . .
.. _ _
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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 14i NO L.
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY '.7` OTHER TYPE INDEMNITY ,„„I BOND U , .
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 ,"J 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 compli ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��
__.._..._.-.......___.__....._____..._.__T.____......__._ t1� -t-+tic�
PLUMBER GASFITTER NAME STEPHEN Aw WINSLOW _.j LICENSE#-12298, -'-'" SIGNATURE
• --- -----;- LLC ;#
MP:,-.,...,,,:l MGF _, __
JP .-; JGF•• , LPGI ,._.,. CORPORATION 'xl# 3281C • PARTNERSHIP M# ,
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS...8 REARDON CIRCLE u.-_. ._m,,. ..._, -.,..__...__
CITY SOUTH YARMOUTH ___x ___T M ,. STATE' MA02664 ZIP rITEL 508-394-7778_ _ __-.,_
FAX'508-394-8256 I CELL NIA I EMAIL accountspayable@efwinslow.com .. .�x.......,..r:.:_ = L.,...-t. ----
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The :Commonwealth ofP/Iassachasetts
zi1 Depalrtnae,:tofIndustrial Accidents
1 Congress Street,Suite 100
py
Boston,MA 02114-2017
`VoS 'aW www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
i1!lieaint Information Please Print)Le,ibl\
Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC
Address:8 REARDON CIRCLE
Grt/State/Zip:SOUTH YARMOUTH,MA 02664. Phone#:508-394-7778
Are you an employer?Check the appropriate box: Business Type(required):
1.0 I am a employer with 10 employees(full and/ 5. 0 Retail
or part-time).* 6. 0 Restaurant/Bar/Eating Establishment
2.0 I am a sole proprietor or partnership and have no
Ill Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8. ❑Non-profit
3.0 We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees.[No workers'comp.insurance required]**
4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care
•
with no employees.[No workers'comp.insurance req.] 12.0 Other
*Any 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:23 COMMONWEALTH AVE
City/State/Zip: CHESTNUT HILL, MA 02467
Policy#or Self ins.Lic.#1821 AExpiration Date:01/01/2010 i
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 the DIA for insurance coverage verification.
I do hereby certij, ---1r the 7(ns and.enalties o perjury that the information provided above is true and correct.
•
Siature: ,r 4 �....9 c--,==:,-- Date: a i31 /i 6
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(circle one): • -
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.rnass.gov/dia •
t