HomeMy WebLinkAboutBLDG-18-000708 HAAS ACHUSETTS NIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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T'pPREll OR OCCUPANCY TYPE COMMERCIAL® J EDUCATIONAL® RESIDENTIAL
CLEARLY NEW:0 RENOVATION:D REPLACEMENT:Imo' PLANS SUBMITTED: YES® 140a.-"
NAPPLIANCES 1 FLOORS—) BSM 1 2 3 4 5 .6 7 8 9 10 11 12 13 14
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VlCONVERSION BURNER COOK STOVE f , I .
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DRYER
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GENERATOR _ .I__ . _ .7E:1
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INFRARED HEATER
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LABORATORY COCKS . __ i lignigniAnallIM: -.f 1 f __
MAKEUP AIR UNIT i r_� I __..I . I. „_ . 1
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ROOM 1 SPACE HEATER .11 I I
POOL HEATER
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ROOF TOP UNIT 1 lj1111111110 . , —
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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 f, OTHER TYPE INDEMNITY 0 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 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 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 compiian with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.•
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PLUMBER-GASFITTER NAME LETSPHEN A.WINSLOW I LICENSE# 12298 SIGNATURE
MP El MGF D JP D JGF L3 LPGI 0 CORPORATION EI# 3281 C ; PARTNERSHIP 0#1.......i LLC D#
COMPANY NAME: EF WINSLOW PLUMBING&HEATING I ADDRESS LLREIRDON CIRCLE 1
CITYj SOUTH YARMOUTH STATE MA ZIP[02664 ITEL 508-394-7778
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FAX 508-394-8256 4 CELL NIA ;;EMAIL accountspayable@efwlnslow.com .
_ _ Office of Investigattons
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1- at .....=ate 600 Washington Street
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�` Boston,M4 02111
'1.,4„;,.44-- www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
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Applicant Information Please Print Legibly
game(Business/Organization/Individual): E,C. WiAsioU.l 00,A.(9w✓tel ,& Vito-r ce) 1 iC.
Address:
City/State/Zip: Ste,kvn •w„r,,,t-t-' t A Phone#: 50B- 399-11e/S/
kre you an employer?Check the appropriate box:
1I am a employer with 20 4. 0 I am a general contractor and I Type of project(required): •
employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction
0 I am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working cfor me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its
required officers have exercised their
10.0-Electrical repairs or additions
❑ I am a homeowner doing all work right of exemption per MGL 11.0 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'
comp.insurance required.] 13.0 Other
ny applicant that checks bok#1 must also fill out the section below showing their workers'compensation policy information.
lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
mtractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
an an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation. {
surance Company Name: (-rp..,..s Mot-veil . Su'rctexC.L.. C vvi
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dicy#or Self-ins.Lic.#: 13 A I A Expiration Date: (—i — aoi`)
b Site Address:3 Gnw' cv)W-e -i -11 A 1 Ct 3 1-‘)({ City/State/Zip: O,-)'4 67
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
i lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
to 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
'up to$250.00 a day a ainst the violator. Be advised Skat a copy of this statement may be forwarded to the Office of
vestigationsthe DIA for insurapetoverage veriitca/on.
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to hereby certify un a /e ains and penalties o•f pe jury that the information provided above is true and correct.
gnatuY • rf " (..".4„,(
Date: Iot);3t1aaol
lone#: >Z`1 ..3T1 777X
Official use only. Do not write in this area,to be completed by city or town official.
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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#: