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HomeMy WebLinkAboutBLDG-19-005145 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Ries=•' -� ( r i-f-�) MA DATE / i/Ii PERMIT#1 L1 T'°°51if t*-,• CITY __\� CIYI-CCU ^� L JOBSITE/ADDRESS 13 C ujni r j* OWNER'S NAME R►'ci-,p r oir.- GOWNER ADDRESS L9 L Je b S e r Si-- ►4 tf, t7176C TEL 5 -105. -cr,36 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL " PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:UJ- PLANS SUBMITTED: YES NO❑ APPLIANCES 7 FLOORS—I BSM 1 2 3 I 4 5 6 7 8 9 10 11 12 13 14 BOILER ! I I 1 1 1 I I BOOSTER CONVERSION BURNER u l COOK STOVE I ' I I DIRECT VENT HEATER I i J I J DRYER 1--- . 1 1 l ( 1 I FIREPLACE � � � FRYOLATOR U 1 .� FURNACE li - GENERATOR GRILLE -INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 1 ROOM/SPACE HEATER 1 ROOF TOP UNIT TEST ! ---- 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER I 1 J 1 1 III, , I 1 l INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW CI— LIABILITY INSURANCE POLICY 0 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 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 are true and urate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / / ' PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 - SIGNAT E MP 0 MGF❑ JP❑ JGF LI LPG!0 CORPORATION Q# 3281C PARTNERSHIP❑# LC❑# COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com off ltC(' .5e91; 3 • /LL VV/IY/ILVIL IYLLLLG/I VJ 111 LLJJNt-IL KJL.66J Department of Industrial Accidents '11r1=�, Office of Investigations jelv, 600 Washington Street • _' � Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information cc ii �, Please Print Legibly Name(Business/Organization/Individual): L•C- tv�sl0;,1; :t i(o- j . .eo !.-,' Address: rdQ City/State/Zip: Sou •v) N&Pr Phone #: 'SOS- 3q4_117S? Are you an employer?Check the appropriate box: Type of project(required): X�am a employer with %0 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction :.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp. insurance. [No workers' comp.insurance 5. C. We are a corporation and its 9. ❑ Building addition required.] officers have exercised their 10.0 Electrical repairs or additions i.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.0 Other thy 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 formation. isurance Company Name: .„; e—A njNu.fctn olicy#or Self-ins.Lic.#: 1 ' a 1 Expiration Date: (—1 — aOi9 )b Site Address:,D3 GNew cv1 i C 11 City/State/Zip: C01•4{r,7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure 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 F up to$250.00 a da against the violator. Be advised t u at a copy of this statement maybe forwarded to the Office of tvestigationst6f the DIA for insura -- •overage verifi on. do hereby certify un e e ains a t penalties o p•jury that the information provided above is true and correct. ignatuTe4- Date: Ca) 1 a©l7 hone#: Sj1:-1c14 - 7 778 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#: