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MASSACHUSETTS UNIFORM.APPUICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�.=ul CITY : SoIi9,51 y, l,2 t. .o Ty. ........._? MA DATE S��S/ii 1 PERMIT#,& lt'-'C £ ' n
JOBSITE ADDRESS 7/J. -I/)/e ii S - - ......./ .._. .._.__.... .-... . _..... .......... ...
_ ....
GOWNER I OWNER'S NAME T�!7y/b..,..�El?'s3�!,�.
OWNER ADDRESS ` `f:-p_. f4.51>,., ......._eft.2T..............: TEL743 .. 1 Vi. ...1 FAX.
TYPE OR ,� x/��✓Dst/
PRINT
OCCUPANCY TYPE COMMERCIAL'._..I EDUCATIONAL;,,, 37o RESIDENTIAL'
CLEARLY NEW:_J. RENOVATION:,...-..ii REPLACEMENT: .: PLANS SUBMITTED: YES..._I NO.R,:!
APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER !_. i: ._... ._ _ I..._ _ ._.M.. ` . _ I_..w. _a I
CONVERSION BURNER �,_... ..__. .. . : . I! -
COOK STOVE I• j t I`�
DIRECT VENT HEATER i .# • I.
I'_._n" I.___ _.__,.__: ...... .1'. , € ...
DRYER gym I
_ .
FIREPLACE M�� ..I,. a . l x l
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FRYOLATOR w
, is �
I . ...:..' _
FURNACE a` . I ,., ..._.I°._ _. : ..'M. t;� 1mY. i I 1 i - _I i
GENERATOR ` 1_, i S 1 I 1.�_ .I i
GRILLE I I - ._I ,. i.--1
INFRARED HEATER t
LABORATORY COCKS .� (: j '._ 1 - i _.•
MAKEUP AIR UNIT i , ,; l .,1 I'_ I _..,_(._.... ' .---I 1 I
I j r
OVEN '.� I 1 _1 ; :�..,�.,� €
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POOL HEATER -:
ROOM/SPACE HEATER :_ .... _...,•
1:_ ':.._.. I ....
ROOF TOP UNIT 1 ::_
TEST ;' i i..... 1 i. 1 ._...
UNIT HEATER I i #.. i_.__ ._i I'•--i _:
1 UNVENTED ROOM HEATER ,, _. I, 1 I I 1 , I------J _ --
WATER HEATER =.:
OTHER I: 1 f' 4 _
_�' is w...!
_. -# �.
a' : I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES II NO ' w
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ..,!,,J OTHER TYPE INDEMNITY J BOND I
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 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 tru nd 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 nc with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE#:122981 I SIGNATURE
MP.- t MGF.:. ,.I JP ,1 JGF:,_j LPG! ,_,_1 CORPORATION•+,#'3281C I PARTNERSHIP M.. :# I LLC „I#.
COMPANY NAME: E F WINSLOW PLUMBING&HEATING I ADDRESS'8 REARDON CIRCLE
CITY SOUTH YARMOUTH I STATE MA I,ZIP i 02664 I TEL:508 394 7778
FAX'508 394 8256 CELL N/A !EMAIL.accountspayable@efwinslow.com
Department ofil agistrgagAccgi:,''NYS
,' Office of Investigations
irt l- .y 600 Washington Street
ti �gyo�spt�on,MA 0 111 •
�'�'fV1111 ww ma s.goIidia •
Workers'Compensatio,u Insurance Affidavit:Builders/Co'tractor Electricians/Phumbers
Applicant Information Please Print Legibly .•
•
Name(Business/Organization/Individual): e 4c.WirS t Q[VokiJo W'tC L ?a.Vevir. Qm J I ei f
Address: 53' (4o w C ircl
City/State/Zip: Soo h Yorw.c,,,t-in N&Pr Phone#: (50S-j14-117S/ •
Are you an employer?Check the appropriate box: Type of project(required):
•
am a employer with •70 4. 0 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
;.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship andliaveno employe These sub-contractors have 8: ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0Electrical repairs or additions
I.❑ I am a homeowner doing all work right of exemption per MGL 11.❑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' 13.0 Other
comp.insurance required.]
thy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they aro doing all work and then hire outside contractors must submit a new affidavit indicating such.
:ontractors that check this box must attached an additional sheet showing the name of the sub-contractom agd.their workers'comp.policy information.
itm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1
rormdtion.
tsurance Company Name: C ki k0:A rrilukeCt.,'t C e_ Coltwtst .✓►
olicy#or Self-ins.Lic.#: $ Expiration Date: ant'-)
)b Site Address:, 3 Ctlrinmev) Aik-e CCvz �y* Y1t�I City/State/Zip: ( ,1 t-1 fo 7
.ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
ne 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
f up to$250.00 a da a ainst the violator. Be advised t at a copy of this statement may be forwarded to the Office of
tvestigations the DIA for insuranee/overage veri a on.
do hereby cent)un e e sins an penalties o pe jury that the information provided above is true and correct.
.ini at& • r Date: [oll 31 1 an k
hone#: •:3�1`]- 7 77g
Official use only. Do not write in this area,to be completed by ci)?or town official •
•
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#: