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Home My WebLink AboutBLDG-20-002064• _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE_ 10/09/2119 PERMIT#,J-N6'O0-4O2' `, JOBSITE ADDRESS 37 LEGEND DRIVE OWNER'S NAME FIELD,CRAIG G OWNER ADDRESS SOUTH YARMOUTH TEL 508.398.9822 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL IZ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED:YES❑ NO 21 APPLIANCES 0 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER • FIREPLACE • FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN 1 POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER • OTHER _ • INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES[f NO❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY g 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 d 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 comp) ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298' SIGNATURE MP[v7 MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION[21# 3281C PARTNERSHIP❑# LLC❑# 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 WORK ORDER 513430$50.00 a Uya . 'S The Commonwealth of Massachusetts 7 -.77 if DepartMent of IndustrialAccidents ISFAVE7 1 Congress Stree4 Suite 100 . -, Boston, MA 02114-2017 r „. '•rzit..,—, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ContractOrs/Electriciaits/Plurnbers. TO.BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeeiblV Name Pusiness/Organizatipnandividua0:E.F. WINSLOVV PLUMBING & HEATING CO., INC Address':8 REARDON1 CIRCLE city/state/zip:SOUTH YARMOUTH., MA 02664 Phone #:5°8-394-7778 Are you an employer? Check the appropriate box: Type of project (required): LEP am a employer with 8 8 employees(full and/or part-time).* 7. El New construction 201 atna sole proprietor Or partnership and have no employees working for me in 8. Ej Remodeling any capacity. [No workers' comp. insurance required.] : ElIQ I am a homeowner doing-all work myself. No workets'comp. insurance required.it 9. Demolition 10 0 Building addition 4.0 I am a homeowner and will be luring contractors to conduct all work on my property. I will ensure that all contractors either have workers compensation insurance or are sole 1 LID Electrical repairs or additions Proprietors with no employees. 12.El Plumbing repairs Or additions 5.0 1 am a general contractor and I havelnred the sub-contractors listed on the attached sheet. . These sub-contractors have employees and have work I 3 0Roof repairs ers' comp. insurance.t er 6.0 We att4 coToratiom and its officers have exercised their ht of exemption per MGL c. 14.0 Oth 152, §1(4),and we have no 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. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 einployees. Below is the policy and job site information. Insurance Company Name ARROW MUTUAL,INSURANCE COMPANY _____ Policy # or Self-ins. Lic.. #:1 909A /01/2020 EvitaU"on r)a t e:°1 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 requited under MGL c, 152, §25A is-a criminal violation punishable by 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 S250.00 a day againststhe violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify un- " " pal s nd pen lties of perjury that the information provided above is true and correct 1 li y Signature: 10 --t .• .4„.., Date: Phone 4:508-394-7778 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority:(circle one): 1. Board.of Health 2.13nilding Department 3. City/Town Clerk 4. Electrical Inspector '5. 1'100)112g-Inspector 6. Other Contact rerson: Phone #: