HomeMy WebLinkAboutBLDG--19-002068 5%" N ASSACHUSE T TS URFORM.APPLICATION FOR A PERMIT TO PERFORM OAS FITTING WORK
� V• CITY : Ye?((02_)77,p 1 . .._... I MA DATE 76;•. /, 1 PERMIT#&D&/? C
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JOBSITE ADDRESS:*�_ .6E/de yry .Cds J-o.. (1,401 OWNER'S NAME ". �/.j/C_ „ O c✓r✓v'lt., .
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OWNER ADDRESS ._,,S _. L ..._..._..........__.... TEL 27 2y, ;FAX;
TYPE OR OCCUPANCY TYPE COMMERCIAL'___€ L _ EDUCATIONAL -1 RESIDENTIAL'21.
PRINT
CLEARLY NEW:':.j_ RENOVATION:"._; REPLACEMENT: ,I PLANS SUBMITTED: YES_i_i NOi,.-J
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER • �; S i _m__.:
BOOSTER ?_-. • ,. ---;._ --. '.-.-. 1 ..-.3 r 1' .__._.,' ...-.- _ __ -I L. .. _^ 1 i___.---_ f.
CONVERSION BURNER --1!_..--..—_ T'.___-J i ! i€ 1 f ! I'_—.,...21._ 1"....__ -....-_._1 s�
COOK STOVE ! I'. '.,.:-:._...I i w.._J'....4_....___
DIRECT VENT HEATER i . i._.a...... ',._._...'._ I mi• t i _ �i d '._......j'.�:=TK .—.._.>
DRYER
FIREPLACE 1 i .�l .-_.. € E:_ . i~., .w.1 ._..,.. ...._
FRYOLATOR i
FURNACE ' _W.1 €' n1 : i -- - . -I. ._ ,I,.. ,...
' GENERATOR J i •I. ,.. ' ..,,.._: .1
GRILLE : 1 ' i' I'L2, t • .--��f
_ _ 1 I' F.....
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INFRARED HEATER r: €; _�� }. �1,• _ _l �_..1..�..i ^�v�'_ ,a` - _ . ''". .
LABORATORY COCKS i 1 _.•. . _. __ _ 1 • I- i °`
_MAKEUP AIR UNIT • r - } i i tit 1 k •
OVEN r r. I __� 1 .� l 1 € J ___! .
POOL HEATER €
1 r I I I [
ROOM I SPACE HEATER ' I.• =� f is I; `
. 1 1_.__._ .: I r--1
i j. ,G t t ....
ROOF TOP UNIT ... ..Y ! i i.... . :___J 1 I 1-,
TEST • :. {. — if i . . _F ";: .-1 - -1 ;.-... 1 1..._J [ _--3 .
UNIT HEATER i,. 1 F. ._.__1: .. . 1.- -- f •- € I' i€ i!____.. -i
1��1. . . .i.__ f
' UNVENTED ROOM HEATER l' lc__ _ _I I
WATER HEATER-- -. . __. . €. . . .1-- .. .1........ I'- - i. __.k_. . { -_ ..._i .t __II__ }--
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I I NO ...
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY -„�I OTHER TYPE INDEMNITY BOND Li
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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 .j AGENT ;.:..,1>
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are tr -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 co nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' •
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PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW ;LICENSE#:12298 -1 - SIGNATURE
MP..!� MGF..�i JP J JGF Li LPGI _I CORPORATION. #:3281e f PARTNERSHIP.:,..tit*
1 LLC #. '
COMPANY NAME: E F WINSLOW PLUMBING&HEATING J ADDRESS•8 REARDON CIRCLE
CITY SOUTH YARMOUTH J STATE i MA I ZIP i 02664 tTEL'508 394 7778 ...
FAX;5083948256 1 CELL N/A JEMAIL'accountspayable@efwinsiow.com
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i Dep arta'vneuag of ibaag Brltaf ACCM.Gt�w
• ~.. Office of IrraveffgotaloR
600 WWshf iigior,&' st
Boot 088,,, 02111 •
W V rteas >gov/df, '
Workers'Con pens ation Insurance AfdSivit:Batik ergs/CormtircactorrsiBleetrricn tffis/ 'llrmbers
A Teasel Iin ortnamtia®:u Please Print Legi Yv .
Name(Business/Organization/Individual): E ac•W r,py5I o f Qt,0,,,ti6 t,1 L �,' V .` i,etc
Address: (4 tin ) Q_
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City/State/Zip: SoAiet P Phone#: 50S-394-rri
Are you an employer?Check the appropriate box: Type of project(required):
,, 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. 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 10.0Electrical repairs or additions
required.] officers have exercised their
1.❑ I am a homeowner doing all work , right of exemption per MGL 11,❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
kny 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 chcckthis box must attached an additional sheet showing the name of the sub-contractors.and their workers'comp.policy information.
lin an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1
proration. •
tsurance Company Name: Arr},,,.s (`t..3 , C vv„.1
olicy#or Self ins.Lie.#: cei A • Expiration Date: ,—I aD1-7
sb Site Address:,)3 Gr Heal A-NaI CNe ntA, City/State/Zip: Or)4 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
f up to$250.00 a daya ainst the violator. Be advised.that a copy of this statement may be forwarded to the Office of
tvestigations o the DIA for insurarpe overage veri c)on.
do hereby cent un e e ains an penalties o pe jury that the information provided above is true and correct.
igna r Date:
hone#: .c1) • P 7 77X
Official use only. Do not write in this area,to be completed by city,or town official
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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#:
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