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Home My WebLink AboutBLDG-18-007390 ...., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 3 or,,,,, - —4:')‘ ,,,,, CITY YARMOu TH MA DATE OFi/77/?t71 A PERMIT#/3442&- rs �7�f" JOBSITE ADDRESS 33 COTTAGE DRIV OWNER'S NAME RANDY PRADA GOWNER ADDRESS WEST YARMOUTH TEL 508-542-2178 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:4] RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO[2' APPLIANCES 1 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 POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 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 [V' 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 tr a and 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 com lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE# ,l SIGNATURE 12298 SIGNATURE MP g MGF❑ JP❑ JGF❑ LPG' ❑ CORPORATION(i# 3281C PARTNERSHIP❑# Lc❑# 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.corn WORK ORDER 476108 $50.00 j *�� Department ofdtt dnstrtat flccaaenas . _Ml t Office of Investigations 600 Washington Street t' Boston,MA 02111 • www.ntass.gov/dia Workers'Compensation Insurance Affidavit:Builders/CouttraetorsiE1ectriciansiPlpmbers Applicant Information Please Print Legibly s�1 , . �nC. Name(Business/Organization/Individual):t. W r S o l Q(V^^40 0� 1v1 tQ g Address: Q..eozinn Cltr.2r City/State/Zip: Soo '\ *f+r'^o -1i MP` Phone#: '5011-'q`1'11?csJ • Are you an employer?Check the appropriate box: Type of project(required): I am a employer with 70 4.0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 7. ❑Remodeling ;,0 I a sole proprietor omr orto partner- listed on the attached sheet tDemolition — ship and have no employees These sub-contractors have 8• 0 working for me in any capacity. workers'comp.insurance. 9. 0 Building addition - [No workers'comp.insurance 5.0 We area corporation and its ci 10.0 Electrical repairs or additions (� required.] officers have exercised their �\ right of exemption per MDT 11.0 Plumbing repairs or additions ❑I am ah[No workers'e doingo all work .1 and we have no 12.0Roof repairs myself.[No comp. c.152,§1(4), P insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] q� toy applicant that checks box Nl must also fill out the section below showing their workers'compensation policy information. \\ Homeowners who submit this affidavit indicating they are doing all work end then him outside contractors must submit a new affidavit indicating such. . :ontractors that check this box must attached en 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: t ',.,_.1 �!C� t1(di pt ti/ to_ �� . olicy#or Self-ins.Lie.#: ]8 D.] A Expiration Dam:_ ant sir Site Address: 3 Cnnrurn` eJ. AV--Q.)0,,e4 '• ['V:\' City/State/Zip: d.•i""I 7 .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure 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 d aa ainst the violator.Be advised tjtat a copy of this statement may be forwarded to the Office of tvestigationnss theDIA for innssurape overage veri ajon. I do hereby certify under ens an penalties o p jury that she information provided above`is true and correct. ( �l Date: td-\31 t a0o- ianatuTei //�r.>_ 'none#: Si19,• ,ttI ')77S 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#: