HomeMy WebLinkAboutBld-17-006561 i iV;IASSACKFUS>n u TS",,NIF ORTI APPLICATO'i FOR A PPRCMil'iT TO PERFoRm GAS I°II T u I N7e WORK
_^ �� ., t PERMIT# V//�G" 45
� P, CITY ,. ._ .1I s.—0-j- i MA DATE � )'� '
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JOBSITE ADDRESS ...;.. G.? )t_I.6=..�( .,) •-__Lc, ,...-....OWNERS NAME, A V_i. . ,.-�..jr1-g". cx �. ..... n Y.�
OWNER ADDRESS ' .... 0„ _ _. I TEL'`. ,---.1,,,- .,;t,— I I, .FAXS
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TYPE OR -�,.!OCCUPANCY TYPE COMMERCIAL... EDUCATIONAL' RESIDENTIAL<:c'�
CLEARLY NEW:_? RENOVATION:'-- REPLACEMENT:,....1,_:,--7 PLANS SUBMITTED: YES NO-CZ,
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _:_._.--.-„� _ `.._,...._: _ _ —
BOOSTERi
CONVERSION BURNER £ ` T
COOK STOVE s .... t .. .,.. _.. ..:. . r. ..
DIRECT VENT HEATER ._wr_„ . ,. .. w j.�:.., �..' .....- _ W .. . j !
DRYER mI _.. .,_.,....1 _ a� _
FIREPLACE n, _.,i ... ...i _m._
FRYOLATOR ! �,-. . _1..r... .> . .� n,.. M. ..-..._, v
FURNACE _ - .n_-..: K ..,..:.,, ri, m _.r..,. _.-,,,...,,'-�
GENERATOR �„ ...--....` ..._. ,.. _,. _..,.,.. .. ....w.. M . `•...,...._ . _ _._...
GRILLE ..._
INFRARED HEATER .... . >..: _ y ,.., _.. —_J,_ n? -_..m_ _ .
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LABORATORY COCKS __'.-_ _,5 __.._ .v_ .___ . .__.._.. ...._.._.
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MAKEUP AIR UNIT _j ...... ..,..-I .._ . --' w.: ,,.I—___, .... -.-
OVEN
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POOL HEATER •
ROOM 1 SPACE HEATER • ._ ' `•--...( ---j - ,' I�-- - _ .. .i _- _ -
ROOF TOP UNIT ; -.F-_,_,:-�_-- _ a..._.,: ._— - �._.,,_1.._I• -....�.. ....
TEST
UNIT HEATER . . . . . r
UNVENTED ROOM HEATER . _ . :_
WATER HEATER ` `
OTHER .i,, _. __. ' i . _ � ~.' _,., 1 !' . .
_. .._._. ,_.._.,:. ...m.....,__m,. .r ._.. -.-,�._._... INSURANCE COVERAGE .._ .
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I„!,!NO ',,.,...
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW i's"-,
LIABILITY INSURANCE POLICY I. OTHER TYPE INDEMNITY .FJ 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 _I1 AGENT U
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 corn ance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws,
PLUMBER-GASFITTER NAME STEPHEN A,WINSLOW r _M ,_.j LICENSE# 12298_'- ' SIGNATURE
MP!..�.I MGF w.,: JP .-; JGF• _.` LPGI pa, CORPORATION /1# 3281C p - PARTNERSHIP w„r#___,, „�,__i LLC•„�;#-,�_ ,, _•
COMPANY NAME: EF WINSLOW PLUMBING&HEATING I ADDRESS.8 REARDON CIRCLE ,. o
CITY SOUTH YARMOUTH _a___ _ ew„ _ j. STATE:MA ZIP 02664 TEL 508-394-7778 � _ m._r•m _; •
FAX•508-394-8256 1 CELL NIA ;EMAIL accountsmable@efwinslow.com -- � �_ ...
The Commonwealth of Massachusetts
11 ' r ' I. Departrt ent of Industrial Accidents
- 1 1 Congress Street,Suite 100
I 3 oston,MA O2114 2017
N:b �>4. www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print]Legibly
Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC
Address:8 REARDON CIRCLE
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City/State/Zip:SOUTH YARMOUTH,MA 02664. Phone#:508-394-7778
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Are you an employer?Check the appropriate box: Business Type(required):
1.111 I am a employer with_� 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 7. 0 Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
• [No workers'comp.insurance required] 8. 0 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]** 11.0 Health Care
4.❑ We are a non-profit organization,staffed by volunteers, !
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.#1821A Expiration Date:01/01/201 0 '
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.
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I do hereby certi , r thens and enalties o perjury that the information provided above fe is true and correct.
Signature: d' 1 a (3!Date: f 6
Phone#:508-394-7778
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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.mass.gov/dia •
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