HomeMy WebLinkAboutBLDG-18-004262 f\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .
W_ CITY ! W�� ._ •'3j MA DATE / /8 PERMIT#Rid)ir/7- -.
JOBSITE ADDRESS' 2 1 �/l1�tL i 2D �OWNER'S NAME I_Q d �° � 5
GOWNER ADDRESS 5. 1 TEL 1 . l` b FAXI__., . __I
TYPE OR OCCUPANCY TYPE COMMERCIAL(= EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:0 RENOVATION:CI REPLACEMENT:El PLANS SUBMITTED: YESO NO-
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APPLIANCES 1- FLOORS--I BSM 1 2 3 4 5 6 7 8 9 10 11 - 12 13 14
BOILER I_ I-. (-mil 1� I ^ I 1 :I. �I._ 'I_.. :i _ �_T-�l• --BOOSTER 1 I I( I_(_`"._._r..._.--,12..wi._.w.•I ;I .7,7 ,I ;( .I., L. �:
CONVERSION BURNER J L.._ ••1_. 1: .a.. I_ - .[7 `1.. .47 :4_,___I`I .. _ 1•----- I'I_ -,-.-
COOK
STOVE I _ I. _ `T I._ i ''r —
DIRECT VENT HEATERL...._.., ;1: _TLC 1._., i1._....__.L. T L, lA: .7..I r L., •1„., . 'C, ,_!.1.„,„... -..:-, \C l
DRYER 1_ -;i-....... _I..7.-._ �..:...,_._1_..__-._i..__7 [.. .y'1�.:.-._. i_.,._..._:I :,, _•..._71:-.... i.
FIREPLACE Fr_� ;17_ (.- :1-----.1---- :1_ --••I�_- 'r.- {-:----;E- ;;;,7-7.I,,... _ 1 7 i t:7`I (�
FRYOLATOR - [a „I Ir ..._1 . ;r . �' _�,� _ - �_. ,. `I�.� I. I�..__ _M"1.� O
FURNACE 1M: E '.I. ..I. _ ;_. �._._ _1 L �:I, _ I. i, _ .. '
GENERATOR I _: r:( _i_-.__• _� ,1_.. El, I I =< r- I .- 'i r._'I
GRILLE Lx711. i I. (: ! I. 1. - -;I ------; 1:-RHH
Ti LABORATORY COCKS :I. 1 i C._ _MAKEUPAIRUNIT I '1�___( �- '17,- .j 1 -- 1: 1 .L_ fir I---_-. E,1 :1,v °!17-7 �I
OVEN r-..-_;1Y__:['"-- [IJr r 'II -_[ .'I._. ..I , �'1„ - I ,i7V.l__' R`
POOL HEATER 1L _;1- 1- .I . : ;i . .;I;I_ 'I, ,,I _7-••L-,._.:.L-._, ,ic:_:._. :L., : .:.
ROOM ISPACE HEATER I. 11� '(-._ I. -. '1 µ 'I. --_-•I. 'I_wW 11 _v-'1,. _i%-�^E. _'L. _. ':L- .�^IL.�.__.'
ROOF TOP UNIT 1-._.I,^.=il__.:(. `L - I ~-'�J1._ 1.,Y~:I_ 'i •L-:_ .1.__-_:I._�:.:-.: ..,.,.'_i:
TEST I _ L i-'I i----.1---I—__, --7:_-_ -=-,L —.j._ = + -- 'i�~1-
UNIT HEATER I` ; �` ---1__.. - 1 ---��• -_- ---.. I. -_i— 1.. _ ;1-----.1-- 1 --,�� 1
UNVENTED ROOM HEATER I I:::...:L .E.:, ', . i. ;1 .1-._--!L-.... 1__. r_ _ 1 ,- ___ 1- .:__.'
WATER HEATER ( _�,�, I 1:-_ �:_:-=_":1.�..:.1----- =;1:_.,A,.I�--i------::'l, :! ..-: I , I . 1_��•
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~ INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ID OTHER TYPE INDEMNITY J BOND L .
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 best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compli-fir e with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 41111 n
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PLUMBER GASFITTER NAME(S T EPHEN A.WINSLOW ___ ��1 LICENSE# 12298 SIGNATURE
MP LA MGF0 JP0 JGFU LPG1D CORPORATION21#l'328'---=PARTNERSHIPD#L _, J LLC 0#L 1
COMPANY NAME: EF WINSLOW PLUMBING&HEATING I ADDRESS 18 REARDON CIRCLE M w v - �—s� ----.---�_-
�TEL 508 394 7778 t 2
CITY ,SOUTH YARMOU I H .,_-_-�,_....__ ' STATE L MA ZIP 02664 �_ .,,��
FAX 508-394 825_6 1 CELL[NIA _____JEMAILLaccountspayable@efwinslow.com _ _ � b
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The Commonwealth of M Massachusetts
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.gam.a.Almx i Department of lndustrialAcctdents
Nei La Congress Street,Suite 100loston,162A 02114-2017
rip'" 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
City/5#a /dip:SOUTHYARNfOUTH,MA 02664. — _-`�
Phone#:508-394-7778
Are you an employer?Check the appropriate box: ?`S
1.El am a employer with `� Business Type(required):
employees(full and/ 5. 0 Retail
or part-time).*
2.El I am a sole proprietor or partnership and have no 6. [RestaurantBar/EatingEstablishment
7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity. ��
3.® [No workers'comp.insurance required] 8. []Non-profit
We are a corporation and its officers have exercised 9. ®Entertainment
their right of exemption per c.152,§1(4),and we have 10.❑Manufacturing
4.❑ no employees.[No workers'comp.insurance required]**
We are a non-profit organization,staffed by volunteers, MD Health Care
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.
**1f 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 I
Policy#or Self-ins.Lic.#1821 A
Attach a copy of the workers'eonspensati _ Expiration Date:01/01/201
orl oltc
p y ec axation 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. Pe advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I
I clo hereby Gertz the ants and enalties o perjury that the information provided above is true and correct.
Si afore: -- !� -<-_.
Date: l i l t ilif
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:
IssuingAuthorityPermit/License#
(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