HomeMy WebLinkAboutBLDG-20-004627 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
keimgrie CITY 6. ° . 4 rm MA DATE Z / E/2- �a
PERMIT.#0 'a0"004417
JOBSITE ADDRESS I k 5 ip/) cO S(--/•C?j OWNER'S NAME 5 -/ 11-( /7 /V
GOWNER ADDRESS TEL 2,3 y -zolg/
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
PRINT ❑ RESIDENTIAL Vj
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO
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APPLIANCES 7 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE -
FRYOLATOR
FURNACE
GENERATOR _
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT - -
OVEN
POOL HEATER
ROOM!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 _1 /IQ VINV[Et
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ' 32
' u
LIABILITY INSURANCE POLICY ►': OTHER TYPE INDEMNITY ❑ IJONI E `,? ?t,
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required b lC L �
Massachusetts General Laws,and that my signature on this permit application waives this requirement. L, ' ".- -1e. _ p .._
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 true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this pplication will be i compliance with all Pinent rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the Gene�(Laws. 1 O (
PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP❑ MGF❑ JP DI- JGF❑ LPG!❑ i
�CORPORAATIION ❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME R_ P t J `f_ ADDRESS ' (-3 S c
CITY U✓ � / STATE /"4 ZIP 0 (p TEL TEL ) 7 Y Y/o i/ Z Z
FAX CELL
EMAIL +1"15 P/` N, � r (Jo Ce)5,&-A I
: \
The CamJnoravq&h.of krassachuseas
.Deprn-t lent ofIiidusfriaTAceidents
"ai- -I'= 1 Congress Street,Suite 100 _
Vif
— Boston,MI 021112017 ''4..
www.plrrssgov/der
li orlccts'-Compensafion lusoranceAifidavit:Builders/Contractors/Lrlectrivans/PIambers.
TO BE FILED WITH lab.PERMITTING Aw.H ORIIY. •
AppIicantlnformation
Please Print Legibly
Na •
lIle(Bosincss/Organization/Individual):
Address:
City/Statr./Zip: Phone#: '
dreyou a worn player?CLccktbeappropriate bc= Type of project(required):
1.0 I am a cmployer with employees WI and/orpart-time)_* 7_ New construction -
7..E am a sole proprietor or partnership and have no employ=working for me in 8. Ei Remodeling •
any capacity.[No workers'comp_insurance required.] 9_ ❑Demolition
3.❑I ani a homeowner doing all work myself.[No workers'comp,insurance rr9uuuL]t
ID[]Building addition .
4[]I am a homeowner and will be hiring contractors to=duet all wort;on r y pmpa ty.Twill
ensure that all contractors either have workers'compenmtian insurance cram sole 11.0 Electrical repairs or additions
proprietors with noemployers_ •• - 124]Piurnbingrcpairs or additions
5.[]Iam agcnaal contractor and I have hired the soh-contractors listed on The aclard short 13. ofrepairs
These sub-contractors employees
have andempl hareworkers-comp.insinsurance? n IRo
• 14.9Othcr •
. 6.111We are n corporation and its niEc s have=rased theirright emu:mption paMGL e.
152,§I(4),sod we have no employed[No worlias`romp.insurance pa/aired.]
• *Any applimntthatcb=ks burx l most also fill out the scotiem brlowshowmgtbeirwodsas'cpmp>osation policy information_
t llnmeawneox who submit this a f6derit ind5mtarg they am doing all work and then hire outside enbactors must submit a new a$davit indicting sod].
tantraetors that check this box roust attached an additional sb4 showing the name of the sob-contractors and state whether or not those entities have
cnpta es lithe sub-conhadms have empinyeu,they must provide their workers'comp.policy number_ •
IamWIanTIoYa-illd fr PrOVILUITg71,DrfriS"COTIT.eurction btrarancEirar Tny rug3loy cps. B elm is-the poffcyundjobsite
i forencr oJL -
Instrrance Company Name: • . .
Policy#or Sclf--ins.Lic.# ExpiLation Datti:
•
Yob Sito Address - - City/State/Zip:
•
Attach a copy of the workers'compensation policy declaration page(showingthe policy number and expiration date).
Failure to scene coverage as required underMGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00
• and/or one-year iurprisonmcnt;as well as civil penalties in the form of a STOP WORK ORDER and a fun of up in I:2S0.00 a
_ day again ct the violator_A cagy of this statement may bo forwarded to the Of ee of investigations of tine DIA for insurance
covcragc verification_ •
;
I do hereby certify under the panne rmd poultice of.perjury that.the infvrmufimt provided above it true and correct.
•
Sil?naare: • Dato: •
Phone rf. .
Olttal use only. DO rwttrriielee this arca,to be completed by city or town ofaaL .
•
City or Town: Permit/License fir . .
Issuing Authority(circle one): • • '
' LBozrd of Health 2BntldingDepartment 3.Clfy/Town Clerk 4 Itwlectricallnspeetor S.PlnmhiugInspector
6_Other • .
1 . • • .
Contact Person: Phone#: