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Home My WebLink AboutBLDG-24-427 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE I/ib fa LIP PERMIT# C D6-2.11-,4 Z� JOBSITE ADDRESS `t IQ L� wO-Od )C OWNER'S NAME ? )4, (l e A GOWNER ADDRESS TEL • FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:Er RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES T FLOORS 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 _ R Lam' V D OVEN POOL — - - [ 1ROOMH PACE HEATER _ JUL ,LU24 ROOF TOP UNIT TEST BUIL DING IDEPARTMEN_T UNIT HEATER sr UNVENTED ROOM HEATER r WATER HEATER • OTHER ESTIMATED VALUE OF WORK: - • - J INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 'NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY1NSURANCE POLICY Er OTHER TYPE INDEMNITY ❑ BOND ❑ 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 ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application ue accurate to the best of my knowledge and th4Latl plumbing work and installations performed under the permit issued for this application will compile e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, L PLUMBER-GASFITTER NAME f""214- Co w Fo LICENSE# t S'S"`3,' SIGNATURE MP ti MGF❑ JP❑ JGF ❑��'°--LPGI❑ 't CORPORATION IN# 30 g PARTNERSHIP 0# LLC❑# COMPANY NAME i (.41wr� ttb # 147-6- ADDRESS /.0 3 Lk I `�'`-c4✓e 0c CITY c3 ' A S"/1"— STATE M4 ZIP C//t2-"(,�31' 57i f 5--.,// /FAX CELL EMAIL A14 CC2 LA.{U c clA I. Op• Co T_ The Commonwealth of Massachusetts $ i—�!i Department oflndustrialAccidents __;l�pl c 1 Congress Street,Suite 100 ??f-3r Boston,MA 0211 4-2 01 7 ' • �sz=.b -wwwmass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMTITINC AUTHORITY. Applicant Information 1°t��/�,�)C aessPlease Print Legibly. Name(Bnsi /OrganivationMdividaal): *"�1 ( r {t'• 0O 1.112 Address: City/State/Zip: Phone#: Are you a.employer?Check the appropriate boat Type of project(required): 1.0 I ama employer with employees(fug.d/orpart-tip).* 7.❑New construction 20 I am a sole proprietor or partnership and have no employes working for me is 8.O Remodeling any rapacity.(No workers'comp.iowrmce required.) 9 • 3.01 am a homeowner doing all work myself.(No workers' comp.insurance required)t .❑Demolition 10❑Building addition 4.❑Isa hem...and will be hiring contactors to conduct all wodconmy property.Iwilt m ...that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am ageoeral co.actoraad I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sob-comrzetos have employees and have worker'comp.msurancet 6.0We are a corporation and its officers have exercised their right ofexemption per MGLo 14.Dnther 152,11(4),sod we have no employees[No workers'comp.insurance required] *Any applicant that checks boo of must also fill out the section below showing their workers'coups:nation policy information t Homeowars who submit this affidavit i eating they are doing all work and then bete onside comactos mast submit a new affidavit mWnitre such [Contractors that check this boo must attached.additional sheet showing the taus of the snh.conhaaors and state whether or not those enitim have employees.If the sub-coonactos have employees,they roust provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. ^' /r . Insurance Company Name: " """�� Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 certify under the pains and penalties of perjury that the information provided above' true correct Sisabre: i'i.`'i"c-'a-" l— D to e: 7 A, )- Phone#: - Official use only Do not write in this area,to be completed by city 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#: