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BLDG-17-002393 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ° . CITY MA DATE I I PERMIT#l3z/9b'-/7'O6g,fsG JOBSITE ADDRESS' • OWNER'S NAME I P S OWNER ADDRESS I .,.. f,:inE.- -1 TEL Al . 4 TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL 0 RESIDENTIALI1 ' PRINT CLEARLY NEW:0 RENOVATION:[ REPLACEMENT:W' PLANS SUBMITTED: YES 0, NOI APPLIANCES FLOORS--> BSM 0©© 4 © 6 0 8 9 10 0®®ES BOILER • L__-.-.;1-7.IIIII1M1'77NillEIMMINENIIIBMNIINIINMNNBIIIIIEI BOOSTER ET;;-=-111117-1117,11111111111MIIIIIIIIIIIIIM COOK STOVE Ta.,____,,,I L._T.117. -it,...2..t 1 ,I.- ,-.1'„, ...,731..7-_,_tillEMOMMITIRENTITI DIRECT VENT HEATER DRYER I.. -' i_. ,IM®NII®MIII ®MIN FURNACE t— _®tlit., ..,_,Iiik® GENERATOR LABORATORY • UNVENTED ROOM HEATER „..,_MIENiiiiiiiMIMINKINIIIINI WATER HEATER I-- I- OTHER I I.. ilk 'I. _ �i f—— _----- Lw:.-i I. _ .. L_.::_. :_:,I. - ;L. 'I f 7 h --- -- — -1 r, INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO Ei I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY R' OTHER TYPE INDEMNITY E 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 Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 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.est of my knowledge and that all plumbing work and installations performed underthe permit Issued for this application will be in corn ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW _ l LICENSE# 1229872 SIG110enulez MP La MGFO JP 0 JGFD LPGIU CORPORATION #j,3281C PARTNERSHIP OI#1_ ____?;LLCD# COMPANY NAME:!EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE -�V --__ CITY SOUTH YARMOUTHT�� STATE MA ZIP 02664 • �jTEL 508 394 7778 FAX,508 394 8256 CELL N/A !;EMAIL accountspayable@efwinslow.com r' (1.' ,ram i tom 600 Washington Street �•�= Boston,MA 02111 . 6.- " www.rrrass.gov/chat . Workers' Compensation insurance Affidavit; Builders/Contractors/Electricians/Plumbers Applicant Inforcmatio PI,, Please Print Legibly i , Name(Business/Organization/Individual): ,tom'•tt'liA.5 i ova - «�yy,t ci �'1.e.Ck v. i. l etc Address: g' C' C etr Q • . .. . t� 4` City/State/Zip: So,1•k 7cu w0 c - Pc Phone#: 5 a- 14-i'l Are you an employer?Check the appropriate box: Type of project(required): �,.l I am a employer with `70 4. ❑ 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.z 7. ❑Remodeling ship and have no employees 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 10.[ Electrical repairs or additions required.] officers have exercised their i.❑ I am.a.homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions . myself.[No workers'comp. G. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] any 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 are 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-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site tformation. i isurance Company Name: �'/TtY:+-J (;`-) l oA • j'cJ\-&&(1(z• Co^^"`'i`i olicy#or Self-ins.Lie.#: ' 1 A- - Expiration Date: ,k--1. — df&t )b Site Address:D3 '--� r,Aeo Kg-ea-1-4-1, kk4, CtryalA I I City/State/Zip: CO Lib 7 .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure 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 E up to$250.00 a da against the violator. Be advised t at a copy of this statement maybe forwarded to the Office of • ivestigations the DIA for insurapenoverage veri Gallon. on. do hereby cert uhe ains an4 penalties of(pe jury that the information provided above is true and correct. ) ignat ei-....__._...---.---'<, ' / .4 ,:._ 'DI Date: ( 3 i 1 9.0kb hone#: . "il``n`i 7 77X Official use only. Do not write in this area,to be completed by ci-y or town official • City or Town; Permit/License# Issuing Authority(circle one): 1.Board of ealth 2. :uilding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: