HomeMy WebLinkAboutBLDG-20-005820 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITEADDRESS , 6(2l�`7 (i�Cl� 5G�4:�.�AOntZ� OWNER'S NAME (1µi* _ r_-_J
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OWNER DpRESS rr )0673-�1- 1'
TYPE OR RESIDENTIAL
PRiI�i T OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL
CLEARLY NEW:D RENOVATION:0 REPLACEMENT:1 PLANS SUBMITTED: YESQ NOD
APPLIANCES 7 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOILER - 'I.— I-- 1 _r7��_l h -i l. _
L L�_.�:I- 1 L�._ I i f__ (.u�._ I I._..,_.1 . r 1-,-1::-
BOOSTER -- � �¢
CONVERSION BURNER f .-JL 1----_-_:,L I._ -_I I. I,.__ 1____. 1 __I [_ jr
COOK STOVE L�:•f^ r I__„ _L __,_.I_:-I _.I 1 1 I _., 1_____.L __.L.__: 1- 1 _
DIRECT VENT HEATER L._I. C__ f ._. ;Ir ( -11'r�-;I _ !f�__ G- 1I E 1 _= ( -
DRYER =;I -1---;f___ _i f 1.____,1.. _ 1C.-IC ] I----= 1- _ir
t 1 i Li1- =C.�.
FIREPLACE C 'L�1 `'�-� _ - - — - - -
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FRYOLATOR--�-� --�- - ---- -- - � I ��
FURNACE 1.�_�..,.,f ._ Cw......,:(H _i 1_......_n 1 __.. I_.._ .J 1.:.._ I__... .:1 ;1, .�.1
GENERATOR I__I ---r I_ 1 I _ - f- 1._ I_ - 1_L_ I f ],E=1
GRILLE L. 1_ __ I_.___-,1___� ��I 1-.__I _ 1 I _.__f I___• _I__-.:1-.__z I_
R-T COCKS. - L� ;L I I 1 L 1_W.L�� 1�:,I_.___.J I_-1[ ..� I _
• INFRARED HEATER L�.:I 1- L____,L , I I 1 - �- G 1_,___ -
LABORATORY CO � _ �L�
MAKEUP AIR UNIT (n- i -- -:=,�1--.._�1 I r. of i f J='- I�_JL Li I
OVEN . 1 i.L_-__i=1 11-R I 1=1 L L_I I i1�IE.-._.i Li,L--=i 1_.-
POOLHEATER ,i 1=f---- I�. 1LiL J{( I,f_Jl.�. 1 `,f.::2=i ;
ROOM/SPACE HEATER (��L .�--. 1I 4L-___IL--__L=1 11 _�11--1=1 II 1=1
- _ _._ -. - _T. 1 __-_ Li Li f - I L 1,1-_... ,�_.�.
ROOF TOP UNIT �.�L...,��',L__�C.- .�I�...�1 _ IL--A-sf
_[ _L _L-:=Lc_ -is 1r ----L I 11
TEST I��� I C 1 _ 3 FT I IL._1Lif
UNIT HEATER I J f 1_� f _�1_._...�f_._-�I 1---�( ,
UNVENTED ROOM HEATER L f ',I ._ L _ I _-:'r� � I._. t I
WATER HEATER L._�.._ _ (- _.,: L ELL I. L- C C e. _._ - -- L""
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OTHER -__ 1_ ( 1:_._ s I r - i r : I _
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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 _'t NO ID
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E's OTHER TYPE INDEMNITY IT? BOND LI
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 L1 AGENT El
SIGNATURE OF OWNER_ORA.GENT ,-_.- _-_
rzl I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accufat�to their st of my knowledge— -•
Z' and that all plumbing work and installations performed under the permit issued for this application will be in compliant i a Pprtine provision of the
f Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � Y" 44,0
"1 .7- PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE#112298 I SIGNATURE
N MP 0 MGF ID JP D JGF D LPGI LJ CORPORATION[l#13281 C I PARTNERSHIP D#f J LLC D#I I
COMPANY NAME:I E.F.WINSLOW PLUMBING&HEATING I ADDRESS'8 REARDON CIRCLE
I
CITY I SOUTH YARMOUTH I STATE I MA IZIP 02664 TEL 0
FAX1508-394-8256 I CELLS N/A IEMAILI INSPECTIONS@EFWINSLOW.COM I
The Commonwealth of Massachusetts
Department oflndustrialAccidents
'� Office of Investigations
�, =YLafayette City Center
' �� 2Avenue de Lafayette,Boston
,MA 02I11-1750
Workers'Compensation Insurance Affidavit: General Businesses
A licant Information us_nesses
Business/Organization Name:E.F. WINSLOW PLUMBING& HEATING CO IN Please Print Le ibl
Address:8 REARDON CIRCLE C
City/State/Zip;SOUTH YARMOU T H, MA 02664 -
Are you an employer? Phone#:508-394-7778
Check the appropriate box:
1.0 I am a employer with_ 90 Business Type(required): --
-
_: �_em to ees
or part-time). P Y full and% ._._ . 5. []Reih--
2.❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity, 6. Office and/or ting Establishment
[No workers' comp. insurance7. ❑Office and/or Sales(incl.real estate,auto,etc.)
p required] 8.
3• We are a corporation and its officers have exercised 0 Non-profit
their right of exemption per c. 152,§1 4
9: [�Entertainment
4•❑ no employees. [No workers' comp.insurance( )'and we have
We area non-profit organization staffed required]** 10.0 Manufacturing
with no employees. Y volunteers, ❑Health Care
[No workers' comp.insurance nn
ther
*Any applicant that checks box#1 must also fill out the section below showing lheir workers'`s'compensationo policyinformation.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'c
organization should check box#1. pol
I am an employer that is providing wor/cers'compensation in compensation policy�s required and such an
Insurance Companyinsurance for my employees. Below is the policy information.
Name:ARROW MUTUAL INSURANCE COMPANY
•
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.#1909A
Attach a copy of the workers' compensation policy declaration page(showingthe
FAttach a copy coverage s p under§25A of MGL C. 152 Expirationtho Date:u ber and expiration 1
o i u e to se ureand/orov rag ear required unde,as well civil C. es in the poesy number and so a date).
can lead form the imposition of criminal penalties fineR and a a fine pp
f up to
1250.00 a dayagainst the violator. Be advised that a co
g of a STOP WO
he DIA for insurance coverage verification. copy of this statement may be forwarded tope Office
fi e of Investigations of
do hereby cer ' e
the i. ,
ns and penalties of perjury that the information provided abo_-
t riat�ire -p ve is true and correct. ¢
lone#: 508-394-7778 Date: 01/02/2020
Official use only. Do not write in this area,to be completed by city or town
wn official
City or Town:
Issuing Authority(check one): Permit/License#
LOBoard of Health 2.
(] of s Office 0BuildingDepartment 3.0 City/Town Clerk 4, g
DOther •
['Licensing Board
;ontact Person:
Phone#: