The URL can be used to link to this page

Home My WebLink AboutBLDG-23-9589 JMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM v � -- GAS FITTING WORK T', ' CITY: kiGICYY1Cjc T6r\- MA. DATE la 18- 3 PERMIT# bL06,-z3-45 S JOBSITE ADDRESS: a Mk % 9-0 01/4„�, OWNER'S NAME: Y \C ( Cl aI\(J G OWNER ADDRESS: l \ k k 2h C ` J �i TEL FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[3-- PRINT an CLEARLY NEW;❑ RENOVATION:0 REPLACEMENT:iit, PLANS SUBMITTED: YES❑ NO 0 _APPLIANCES- FLOOR-, Bsmt 1 2 3 4 5 6 7 8 9 10 11 1 BOILER 2 13 14 it BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER _ FIREPLACE S FRYOLATOR '') FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK NJ MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER �} ROOF TOP UNIT _ ' TEST Z UNIT HEATER I 4.1 UNVENTED ROOM HEATER WATER HEATER INSUR CE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES .-NO If you have checked YES,please indicate the type of coverage by checking the appropriate box ❑below. LIABILITY INSURANCE POLICY ] OTHER TYPE INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General ,and that y signaturepp on this permit application waives this requirement. ' x SIGNATURE OF 0 NER OR T CHECK ONE ONLY: OWNER 0 AGENT 0 hereby certify that all of the details and information I have submitted or entered Knowledge and that all plumbing work and installations performed under the permit issued for this application wrding this application are ill beIn compliance with e and accurate to the all Pertinent provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME' r !CENSE#Alla SIGNATURE COMPANY NAME: c ADDRESS: LCLAt CITY Aketaaid .� STATE: __ ZIP:___0 !' a FAX: EMAIL' S MASTER JOURNEYMAN 0 LP INSTALLER a ON❑#CORPORATION PARTNERSHIP[]# LLC #` C merit, f3 O . 1�7,12c-SS: The Commonwealth of Massachusetts ;�_ L=�� Department of Industrial Accidents 'eth rl=- I Congress Street, Suite 100 Boston, MA 02114-2017 �E.,` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Arkci u,(An (—?G C h-Zl " CC:l t w Address: —1 (6 i C,,ow e,r Cat I A-1-ti ' City/State/Zip:V\act,, -j� ,( 5c- 9 --3 /, ( �(�. �..�tf Phone#: ,� - -I Are you an employer?Check the appropriate box: Type of project(required): LE1,1 am a employer with employees(full and/or part-time).* 7. 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Rem delinruction any capacity.[No workers'comp.insurance required.] 8 ❑Reoeling 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on mproperty. I will I0 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sol proprietors with no employees, ILO. Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12. Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. I4• Other 152,§1(4),and we have no employees. ' `� [No workers'comp.insurance required.] +J *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infoon.� t��r T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: \ec-t< .JJ-•a.- Policy#or Self-ins.Lic.#: W 9 6�'1 e I3 ii Expiration Date: t� -'� h L ", _ "p ,, Job Site Address: va. ` 11 � .J` City/State/Zip: s.,(ems_ ''. " Viiik Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certij5r under th a' s and aloes of perjury that the information provided above is true and correct. Si nature: "` "-O -'f`«��' Date: Phone#: 5 )-- Official use only. Do not write in this area,to be completed by city or town official City or Town• ' Issuing Authority(circle one): Permit/License# r 1. Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: