HomeMy WebLinkAboutBldg-20-001715 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
YARMOUTH _ �r,+
CITY MA DATE 09/24/2019 PERMIT#g2421' c
JOBSITE ADDRESS 319 MAYFAIR ROAD OWNER'S NAME PENTA, ANTHONY
G OWNER ADDRESS YARMOUTHPORT TEL 508.614.8873 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 121
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ® PLANS SUBMITTED: YES❑ NO
APPLIANCES-1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE 1
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [V7 NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [Vi OTHER TYPE INDEMNITY ❑ 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 ❑ 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 tr - 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 comNance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE# 1229: SIGNATURE
MP[i MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION[V7# 3281 C PARTNERSHIP❑# LLC❑#
COMPANY NAME EF WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com
WORK ORDER 512669$50.00 /`
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Workers'Compensation Insura*O0M1dav w BuilderslCont tctOr/Electricisns/P=lumbei s.;
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Type of Pet(required)
1. am a-�t nb'With �o (full andior parGiiine a
7 ONew construction
� a :hip and.have 10vinployees�working fora xi=la: 8. Romode ing-;_
' '�(Nou tkers' o np inauranrx,requ�_]
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qg aottttaotorsto conduct:ill o4m 1�
ottsure thataZllcont tors either havc.workers'co tiosinsurance or arc sole' 11. l l csal r or,addttions
�e�witlt7to employees
- 12 DPLumbing repai s or-additions •
$ 'aMa l eon**0 d t have hirod:*the sub ontractorsl, ed.on attached tip
• Theso slib-c)ntr ctorahave ebtploiyees aad have workers'comp.insurance l3�rr.00i rePa<its
d.0 r brat►cnandYi �.love; tidd:theuifght of-mrempyoa p MGL:c 0' i
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I(4jt: °haveao ]dyees.(No worketu'"comp intsurance required.]
-' , ,::,',,,11140`,01lOOPtfiSteeirotbelow-sowing their `won 1olIell q. Ions
tllt��ttidieadug they ate doling a[ll work and hire.outside colitractors must submitEa..new:atfitrsvit indicating-sucht,
i✓ i w, 4t an itionel-ste'erlthowing'�name ofthe~subwon actors-anatate whether or not those entitles.lave
.. °ty, i e.•,. - thej�tf provide t it, `, p. 4
-- =e r rfh providingworkers'compensation.Insurance fot:mytiVilfreek,: Bow is hepolcy and)ob.site
t4040016n. .
Insion4 C ' i 'P W MUTUAL,INS RANCE COh11PANX
pb9A , . x iiration] atc.=01101`20; ._, ,
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' Attach a of p hew uornperysation<policy deel ation page'(showin tlhe policy nu mber and expiration date).
Failure:to s4031rO cov e-as uiled under IvT0L 0 1 2,125A is'a criminal violation punish ale by-.a:funenp Witt: 00
and/orone-year`imprisonment,;as well as civil penalties in the form of as STOP WORK O.RD ;and a fine ofup to$250 00 a;
-day a sin t ha elator:A copy ofthiv statement may be forwarded_to li is `001 f motions of the DIA forinsurance
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�ate01 .Do t 404 inthis area,to be completed-by city or town ofieiaL:
City or�Tow n: ,,,:: PermitfLicense# .. .
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