HomeMy WebLinkAboutBLDG-22-1266 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
\a;n.1-- MA DATE_`�Ll.Z.L, 1_J PERMIT# -12,- IZ(o1'
v1;�_s CITY ____..____.YtC!�0 ir:��________.---__.___-.._..__�
JOBSITE ADDRESS h �1:ider Y.lfY0.1f{_it94/1_dual OWNER'S NAME ..h_,11.�
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GOWNER ADDRESS 1.6_1yesi-play c vGk/�-_Q_e _�.Al fj_ l]TEL 71�G 7_ ....1_J. ..3,.___.....FAX _._._ 1
TYPE OR OCCUPANCY. � IYPE COMMERCIAL EDUCATIONAL D RESIDENTIAL ID-----
PRINT
CLEARLY NEW:Q RENOVATION:0 REPLACEMENT: ._: PLANS SUBMITTED: YES O N0 lj
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER .._._._.`L___..._._i i 1 ---•..--' __+ _._.___s .,._.___ I.___._.,1 1' ____.} _ ._..r1
BOOSTER ...... ;. .._.__ . I._
CONVERSION BURNER __...s,_._ ..; ____.
COOK STOVE ti.. ' _.. r.,_.._s_I' I____ . ', _.__ _, ---..'
DIRECT VENT HEATER
DRYER
FIREPLACE + - M�MR
FRYOLATOR
FURNACE 1
GENERATOR +
GRILLE __ —I -
INFRARED HEATER
' 1
LABORATORY COCKS
MAKEUP AIR UNIT 1 ..... , _ _
OVEN
POOL HEATER WIII _. _ . ,
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ROOM/SPACE HEATER
ROOF TOP UNIT I !!! �_ I
TEST _.._....' 'I____
UNIT HEATER ___.__
UNVENTED ROOM HEAT>R---
WATER HEATER - -. , --'
OTHER AINWIlii II _ __ 'MM.W W_^ � ii. '
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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 B NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 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 EI 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 st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complianc i a Pr rtine provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. IPA',
PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE
MP D MGF® JP D JGFD LPGI El CORPORATION D# 3281C PARTNERSHIP®#__,___-__. LLC[-�# �
r" COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
s
.a CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
N' N FAX 508-394-8256 CELL NIA EMAIL INSPECTIONS@EFWINSLOW.COM
N
The Commonwealth of Massachusetts
Department oflndustrialAccidents
_ • Office of Investigations
' Lafayette City Center
2 Avenue de Lafayette,Boston,MA 02111-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:E.F.WINSLOW PLUMBING & HEATING CO, INC.
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH, MA 02664 phone4#_508-394-7778
Are you an employer? Check the appropriate box: Business Type(required):
1.0 .I am a employer with 90 employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ['Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp.insurance required]**
4.❑ We are a non-profit organization, staffed by volunteers, 11.❑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.
**If 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:
City/State/Zip:
Policy#or Self-ins.Lic.#1964A • Expiration Date:01/01/2022
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under§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 of
the DIA for insurance coverage verification.
I do hereby cer' j the ins and penalties of perjury that the information provided above is true and correct.
Signature: Y ^� ..•CIF Date: 01/02/2021
Phone#: 508-394-7778
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(check one):
111Board of Health 2.0 Building Department 34E]City/Town Clerk 4.El Licensing Board
50 Selectmen's Office 6.DOther
Contact Person: Phone#:
•
•
www.mass.gov/dia