HomeMy WebLinkAboutBLDG-16-006983 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
% i•. ii CITY .17)211,� MA DATE i P MI # �/G� 1
JOBSITE ADDRESS: k AME ' ./
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GOWNER ADDRESS -. _ i T 5'QWX
TYPE OR OCCUPANCY TYPE COMMERCIAL .„...I EDUCATIONAL �' RESIDENTIAL ,d
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()AI CLEARLY NEW: __,I RENOVATION: ....„1 REPLACEMENT:/ PLANS SUBMITTED: YES I NO.y,,,�
1. APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOOSTER ,-. . ,m � .. i
Cl CONVERSION BURNER :, _ --4,_. __. K. 3d_M_I ,._. .._I_._._.. _I i y �.. ___1
COOK STOVE ._..,.,__ _I I I_ I__... ' _,_.......
DIRECT VENT HEATER ___I, ! I _, _.,.._I,__I_ „.. :, I
DRYER .. __ I I a'_..._.__! I I I
FIREPLACE I'._.._ ' _ __. I I I. I , I
FRYOLATOR .. w._ ! t . _ I I I I I I_ 1
FURNACE f I__: I „ _ I I I J I
GENERATOR _ I I ,..._3 . .. __.J 1 ! I 1 I' I
GRILLE __ i 4 I_... ___..1_.._..__....1 I .._ 1 I I . I
'‘.1) INFRARED HEATER ' _1.... w I__ . __ I _.I I ___.__I = I
J .LABORATORY COCKS ......i _._ i ._ I. i I ...__. _._._J
MAKEUP AIR UNIT # . I ..�. (' __.__I .i J_�._._._..'
OVEN J .....,. ___I ___....i-_ _ I_.. �___1
POOL HEATER __,: i_ I 9 -- 1 E__ P _ 1;
ROOM/SPACE HEATER __I'
ROOF TOP UNIT l I i i _..-...I _.
TEST _. _ € _ 1!__ _S
UNIT HEATER I .,, ____, ,
UNVENTED ROOM HEATER I i_.__.._.! i
WATER HEATER
OTHER _ J._ _ _. I j __. i
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____...___.__..__.._LL_ ._______._-__.._..._ I..._ I __.__y_I
..I 1.,._».,_._._ .._ .________ -.... -,- .,_.. ___.... 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 v 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 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 pro 'sion 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 SIGNATURE
MP .! XMGF __, JP _,. JGF = LPG' CORPORATION /I# 3281C < PARTNERSHIP __,# 1 LLC # I
COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE _ _
CITY SOUTH YARMOUTH STATE MA ,ZIP 02664 I TEL 508-394-7778 I'
FAX 508-394-8256 i CELL M EMAIL ACCOUNTSPAYABLE EFWINSLOW COM 1
....____. 50
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The Commonwealth of Massachusetts
_ Departramin afIndustrialAccidents
Office of Investigations
B?Elp_ (t 1 Congress Street,Suite 100
N= Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): E. F.WINSLOW PLUMBING&HEATING CO.,INC.
Address:8 REARDON CRCLE
City/State/Zip:SOUTH YARMOUTH,MA 02664 Phone#:508-394-7778
Are you an employer?Check the appropriate box: Type of project(required):
1.12 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
2.❑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. employees and have workers' 9 ❑Building addition
[No workers'comp.insurance comp.insurance.:
required.] 5.❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c.152,§I(4),and we have no 13.❑Other
employees.[No workers'
comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees.If the sub-contractors have employees,they must 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.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Policy#or Self-ins.Lic.#:1794 A Expiration Date:01/01/2016
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 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations oft IA forinsurance'co erage veri cation.
I do hereby certiftt un erins
and enalties erjythat the information provided above is true and correct
c 2016
Signature: Date:
Phone#: 508-394-777
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
'Phone#:
Contact Person: ""