HomeMy WebLinkAboutBldg-18-004295 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .
Il 1�=s• CITY jU 7. . _'- / i, MA DATE[7/v24/1 ]PERMIT#hX-db-lira) A, q6--
JOBSITE ADDRESS Lk'7'} � ✓ �' .. OWNER'S NAME- YX2 ✓I1 G?/-'I-•
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TYPE OR OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL 0 RESIDENTIALE�i-----
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CLEARLY NEW:El RENOVATION:Li REPLACEMENT: PLANS SUBMITTED: YES' NOD
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INSURANCE COVERAGE + I
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES of 1 NO [ I, r
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ; C
LIABILITY INSURANCE POLICY M OTHER TYPE INDEMNITY[J BOND l 1-`
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OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1
Massachusetts General Laws,and that my signature on this permit application waives this requirement. P E
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CHECK ONE ONLY: OWNER 0 AGENT i - —•� --~ `-)
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 any 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 compile 'wit 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 1 LICENSE#112298 '•-- SIGNATU C>cl
MP D MGF El JP 0 JGF® LPGID CORPORATION( # 3281 C PARTNERSHIP D# LLC #L _,�
COMPANY NAME: EF WINSLOW PLUMBING&HEATING a ADDRESS�8 REARDON CIRCLE 1
CITY I SOUTH YARMOUTH _ tTM_ . STATE MA j ZIP 0266TEL 508-394-7778 i
epFAX 508-394-8256 1 CELL N/A s EMAIL accountsp able@efwinslow.com `I `
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The Commonwealth ofli2assachusetts
i• 1 1)e arfrraent o
W P f InduscrialAccidents •
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1 Congress Street,Suite 100
Boston,MA 02114 2017
•: www mass. ov/dia
Workers'Compensation Insurance Affidavit:general Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A licant Information • Please Print Le ibl
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:
1.� I am a employer with '� Business Type(required):
employees(full and/ 5. ®Retail
or part-time).*
2.El I am a sole proprietor or partnership and have no 6 ❑Restaurant/Bar/Eating Establishment
7. El 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. ❑Entertainment
their right of exemption per c.152,§1(4),and we have 10.0 Manufacturing
4.Eno employees.[No workers'comp.insurance required]**
lWe are a non-profit organization,staffed by volunteers, 11.0Health 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 policyis
organization should check box#1. pe required and such an
I am an employer that is providingworkers'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 I
Policy#or Self-ins.La#1821A
Attach a copy of the workers'compensation policy declaration page(showing the ptol cDnumber0and 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 certi the airs and enmities o perjury that the information provided above is true and correct. '
f1/
a Si nature: r "-. t J
Date: t t f ,
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#:
wwwcmass.gov/dia