HomeMy WebLinkAboutBLDG-18-000475 A7,,,,, /gym✓i)
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
,,1L- CITY ----------_.._... - _-
';_ _r1 ��% -�__ ,�:�; MA DATE „75 /�;P MIT#/,` Db.-17-OOd'175
�1 JOBSITE ADDRESS / ar) J7, ' OWNER'S NAME , /964-610 ?
c7--) G OWNER ADDRESS (,�"'CjjitY7ih NAM ITEL[ �IsoFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL
PRINT C� �{ RESIDENTIAL
CLEARLY NEW:E1 RENOVATION:D REPLACEMENT:(�',' PLANS SUBMITTED: YES JJ NO -
APPLIANCES 1 FLOORS-► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER (. .— 1 1 :I 11 i !l _ ;1-_- 1 1 `�`-( _i
BOOSTER I_ II. _ 11 -I, FI :I. ,I �!1. II I `I }I ;1 117.(I. I
t CONVERSION BURNER r"—I LL. -( I I . . . --- I I I_. --I i _.._..! I I ► ( 11-1 11
DIRECT VENT HEATER I _ Ii.-----i TILL 'I 1 `� I '1�1 it 11 ti- vl
COOK STOVE I_�__: I I ;1 'I �1 , 11 DRYER I I ---1r il� ,._,1._.-�-.I-._ iI . ..'sl. fr __I_ ----1 - .l -'I --TI 1l-- 1
FIREPLACE I .II. 'I "I_-_- '1 3:._...II. iJ ;1 :; I 'I,. I
FRYOLATOR I_ i I._ I F "`.�L. I _ sl 1 til 1_�__-'F 1 I... . -11 7_1 h--((---'
FURNACE I. ;I--.I 'I - I �_,... ,1-- I -'I -I-- :I t h 1. f I 171.
_GENERATOR
1 I 1-- 1 it: ---,� ! ! --i ---_;� ;1----
_GRILLE I:.__ 'I 1I_,.. _I . 11r I_.. II ti :I_.. :1 . 'l.r ) 11_._ --11 - --e:
INFRARED HEATER I_ ..: I l.—. l `1 'I _I .;�— I _1 'i ,_ ,
.LABORATORY COCKS I _ '( _ I_ -- I 11 '1 J I.LI"5 �. I'� _
MAKEUP AIR UNIT I_ 11._ __.'i 1- j`" A. .II i1 ([_ ._ I_. it._ iIt `jl, II'_ `-
OVEN __�t1 IL_ II :_ fl___ ilT sj ' ..`.I_,-.'I ._ i r1 _111 i —'t__
POOL HEATER I,, I r1 I _- I ;) 1 lJ l , I I . 'I ,I 1i—
ROOM/SPACE HEATER �rI I1. i. t ,.. 1__. ;I . I_ ;I _ .— ...(f_- rl_ nFI, C . JI, —
ROOF TOP UNIT I .1! i l 11 ',111 1 ' 1_ `I 1 1� ! i. t
TEST :�:r .. .. .' . .. ' _ 1 1 _id_ __ '1 `I _II_v j1 i 1.
UNIT HEATER 7.i[. ',I r1— V _. _::1 .�I�JTI—...I i - I�~_.
UNVENTED ROOM HEATER I 7'I :I _'I--` i r l_.___.t'�-1. .. -;I 'I__. I,- . i i _ (1 LJ— ._
WATER iEATER I IL.. -:I. I . l.. .. .1 _ I_ _'i.
OTHER 11 __ ._II II_ t1� !I.__ 1 . ..'I I �`. . 1__ 114-fI IL_. .kl, i
I I I IL I ! I
i� I _ I I 'I
1 • ..... .m �.,_... :I : 1� I 1 _Id I - - I -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 El NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E', OTHER TYPE INDEMNITY El 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 Li AGENT Li
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 best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in corn Nance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ii / )
_�2� 7-t1�'.4-r.„-Ce‹C_
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW 1 LICENSE 4,12298 SIGNATURE
MP Ei 1 MGF El JPZ1 JGF D LPG],� CORPORATION 1-7;#y3281 C Il PARTNERSHIP # -Ii LLC D#=
COMPANY NAME: EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE _I
CITY SOUTH YARMOUTH _¢_ STATE MA !ZIP 02664 TEL 508 394-7778
FAX 508-394-8256 ;I CELL N/A liEMAIL accounts able@efwinslow,com _ _
_ Department of industrial Acctden=S
o,Y l_fl Office of Investigations
f_i:ftil=5. 600 Washington Street
-:=311= Boston,MA 02111 •
=� !-'
c,.,ur www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):e•c•W+O,stO...l QtJ,...tOi✓tc( c_0to.A;� Qs)
(3' 1?-1((
Address: KP '� .:1 CraP- 0a
City/State/Zip: Soo v\ irt" MA- Phone#: `50S-5c14-1't?Sd
Are you an employer?Check the appropriate box: Type of project(required):
XI am a employer with 70 4.0 I am a general contractor and I 6. ❑New construction Ni
employees(full and/or part-time).* have hired the sub-contractorst. ? El Remodeling
�`
0 I a sole proprietor
partner-
v
shipip and have no employeeslisted on the attached sheet.t These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'camp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5.❑We are a corporation and its 10.❑Electrical repairs or additions \
required.] officers have exercised their1. or additions
right of exemption per MGL 11.0 Plumbing repairs �(
❑I ran a homeowner doing all work c.g152,§1(4),and we have no 12.0 Roof repairs M
myuran e r workers'd] comp. employees.[No workers'
insurance required] 13.0 Other
comp.insurance required.]
1ny applicant that checks Nix fit 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 subcontractors and their workers'comp.policy information.
im an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site 1
formation. n�-(suranceCompanyName: l�lyYlO....-i CA.)i-VoJI nfn CZ, Coyvy .
olicy#or Self-ins. h Lie.#: 1
gAl PrExpiration Date: C-1- ant-)
ib Site Address: 3 wee.•11-1., 1 Ceg """ 1'1 City/State/Zip: O,)14 fo 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
Iup to$250.00 a da :::'net the violator.Be advised .:t a copy of this statement may be forwarded to the Office of
tvestigations. the 3e
DIA for insure - ,overage verii on. t
do hereby certifil
u penal`es 7jury that the information provided above is true and correct.
tt Date: (a I a01er
i9 at>ff- _.
hone#: StA•3c '-777g
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#: