HomeMy WebLinkAboutBLDG-16-006977 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFIRilii GAS FITTING WORK
°. �- CITY —_ _ MA DATE M -I PERMIT#/, p dria, /
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JOBSITE ADDRESS Cx.l f Y�(��_ �Y�T OWNER'S NAME I diMI-
OWNER ADDRESS Prnt° k( TE _ FAX I )
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL LI RESIDENTIAL[
PRINT
CLEARLY NEW:0 RENOVATION: :;; REPLACEMENT: PLANS SUBMITTED: YES», NO[I
APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
_._..___
BOILER I �I_-_-..._I I .. . I. .._�,. i--- --�i- !I. .. _l l.___..-_I! __ . „II____ I
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BOOSTER 1_—iI_ _.. '1---- !- '1--- _.'I_ ....:1...._ _II. . HIT- I. I.... il___ .--11- I[----'I- 1
CONVERSION BURNER [ II._
___
COOK STOVE L__ __ : - . _,I_ - L _w_.11-.- __ ! I I-__ I I - i I I._.—_ .II,__ II_ :117
DIRECT VENT HEATER I_- II__.__11._�_�! . . I IA .1._._.__�L...- .....;!_-_ _!1- _ .il_.._._?1 .. _E!
DRYER I I. - ,_ir__ I_ I . I- il.. . .-I- _Al _ _. _ i
FIREPLACE !-....m: I.----,1--_-__„_-.. ,I ,1__ 1-= i:----1!. . _;_�----.� ,,_._.__1._ 11 11...__I
FRYOLATOR I i. I __ I I l i.- I I +i I i. —I _ !. _ l r `I .
FURNACE . _ II_, .!1 - _ f! _i 1 , .I-_`' .. — -
GENERATOR I..---- `I--_..._I_. .. (_ ..;!...._,:__ _f!..._ ..il. ll - .
GRILLE _ i 1---.1-—, 17.71-------I-- -°I . `,j-`_--- 1 _. —._
i. I - 11— I �,!
INFRARED HEATER t_ _....;I. . ' . . I. . _ i__ I. '1_ _-_ I-. - I - '!- '1--_I1. ..__ ! ..i . I _1 I_..-;
LABORATORY COCKS .____...—..-- .-- --- -___-- , _
MAKEUP AIR UNIT - I_ !':1.---'1 - !I I— L_ I _il — F. 1_. -- -,I____'I�___ r i1._ . _..II_
OVEN 1 .-i 1 _ I I I :11_-__.. II__.11 _. t _._. _ _
ROOM I SPACE HEATER �i1 ._ .- __-._-II_._-.--fL ._ I___._;I .. i_ _'I-_--__,I_. , - -_
_ II:- _-!'I_____I
ROOF TOP UNIT L__-I 1T-_�I II. I Imo-.`I--- --I I.. . :I, _ I---- 11— I :I- - _'!I. ,1--- I I I
TEST L.1_-.!.
_ ._ 1 _-._ 1 - 1-- I I_ - 'I. ---I-_ . I ._ II .. I.____ I- '!— II— . -UNIT
HEATER _ _ I.. I . :.I 1.1. ,- _.. _ I_ '. 'I it .1 'I
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UNVENTED ROOM HEATER (7 I . 11.. _'•I----1�_ `I._._. 11. I:_.._ I.I� _ „,_'( - 1 i1 i i ._. -- (-
WATER HEATER I r I! . . II 11 '1 ! . . I'. I-- I. I I .I 'I. ii, [ :
OTHER Jf �I0I__... 'I_ . I L i I '1. —. 1 ._ .'1.. ;1�-- --;I_- -z _1- i! .-.11..,-- 1
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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 (NO E
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY u 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 [I AGENT El
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 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 compli e with all Pertinent provi on of the
. Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME[STEPHEN A.WINSLOW _ il LICENSE# 12298 SIGNATURE
MP LJ MGF I 1 JP D JGF D LPGI 0 CORPORATION • #T# 3281C �11 PARTNERSHIPr# I LLC D:#��II
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ..I ADDRESS 8 REARDON CIRCLE 1
CITY SOUTH YARMOUTH — _ _-__ STATE MA ;ZIP 02664 1TEL 508 394 7778__ Y
FAX 508 394 8256 CELL N/A ____.____.Y, _ .---7
IEMAIL accountspayable@efwinslow,com
3 /g0
1.i2 I=f Office of investigations
ji I
" - C 600 Washington Street
r Boston,M4 02111 •
Lin sa www.ntass.gov/dia.
Workers' Compensation l[imsurcannce Affidavit: I:niiderrs/(Conntrractorrs/IElectrrieians/Phambers
Aplilicant Information Please Print Le ig bll
Name
(Business/Organization/Individual): ,c•W;s 1 Qva Q(V,+A.i«ct o„ ,, (i J I�c,
0 6
Address: ,Pc to CI(6.1Z—
City/State/Zip: Vic,, Ycrbsrn t-Or Phone#: ct` -7TT
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.t 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
have exercised their 10.0 Electrical repairs or additions
required.] officers
I.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs D\
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
thy 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 check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation.tsurance Company Name: j� — ��p•. ( %-)ki C ,L.LivisUrCit(1 C�. C L'j.^-..vv a
,
•
olicy#or Self-ins.Lie.#: k' .i A- - Expiration Date: k---1 " -Oi )
)b Site Address:,a3 (0,(v,,,Acyn\"ec R ASS , e Z IA.;\4 City/State/Zip: 1)t,Li to 7
.ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
ailure 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 day against the violator. Be advised that a copy of this statement may be forwarded to the Office of •
tvestigations the DIA for insura ee overage veriftcalon. f
do hereby certify un e e ains ane penalties ojpe jury that the information provided above is true and correct.
. / )<A .. ..
ignaturei Date: ( 3 i1 � '
hone#: .S]l•`3``i "17 f X
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
Contact Person: Phone#: