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iJMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
lc'� CITY - _�-,,..._._ __; _ t�GO o'�/ '
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W _ - __-- — MA DATEL.7._/2 1 PERMIT /, �"'/�
JOBSITE ADDRESS /6. G RG iE' L-oo p -�I OWNER'S NAME . ,7w g� (,1G.-0 ii T
OWNER ADDRESS L _ _ � — .—_ i TEL[5d 7 2 V FAX -
TYPE OR OCCUPANCY TYPE COMMERCIAL ET EDUCATIONAL — RESIDENTIAL
PRINT ._I
CLEARLY NEW:E1 RENOVATION:D REPLACEMENT:J PLANS SUBMITTED: YESD NOE
APPLIANCES T FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I IF 17.7 7.711... ` _.. ii. .._.li I7 --fl._ _-i_....... 1. i:i... T T
BOOSTER L�T i 1 I_. ....FL h :1..... I. I____— T.-- tl-,- {I- ,_ l_ .rF 11.... . I
CONVERSION BURNER J_IIIIIIIIFll
J . 1W. •
COOK STOVE I i . f_:.,
DIRECT VENT HEATER L.-.._C _E DRYER ..FIREPLACE _FRYOLATOR ..i FURNACE ..GENERATOR I_ '
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GRILLE �®®�®I�®®I ®®
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I 1.. ._ . IIIII,U1$P,
UNIT HEATER I .'E.-11.. . _ia r ..I.I I .. 1 I I-.1 . �iI I . l [I �I 1_.
UNVENTED ROOM HEATER r_-- I.. €I.., ,_..`I� y.-i ~.-1. il`_`I <I .._'1._.. . l..-. I. . . -:. .I _.. it ;IL
WATER HEATER 1.__— I .. II ._ il7 --`I .. .`I . .. i . . 'I----. 'h---li _IL. ....I .-..,•I. .3I. ...._ 1.--) - p
OTHER ft.---i l
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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 U
. ,
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY II OTHER TYPE INDEMNITY El BOND EA
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 0 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 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 compli a with al Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '/ n
PLUMBER-GASFITTER NAME 1 TEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE �G(/
MP E 1 MGF U] JP UJ JGF 0 LPG!0 CORPORATION J #ILL IC. PARTNERSHIP D#[ ;LLC Q#J
COMPANY NAME: EF WINSLOW PLUMBING&HEATING `ADDRESS 8 REARDON CIRCLE _ _ - _�;
CITY SOUTH YARMOUTH —73.
STATE rMA i ZIP 02664 ITEL 508-394-7778
FAX 508-394-8256 ,1 CELL NIA l EMAILj accountspatable@efwinslow.com - � � � ,
Department of in..nstrttpl Accaalernn
A:',I. i Office of Investigations
600 Washington Street
�/ Boston,NIA 02111
"�'^� s. wwwwrrnass,gov/dia •
Workers' Compensation Insurance Affidavit: Builders/Conntractores/Electricianns/Plamber°s
plicant Information e Please Print Legibly
arise(Business/Organization/Individual): L-'C•kt�1,r�Sit Ova Q svivi I2 0-e.a- , QG-, (vlC.o
0 • J
"ddress: U fairl C i rc - T . ..
;ity/State/Zip: Soo Sv icry c,.r , 4 Phone#: '50S-3 9 7'1`7C1 •
re 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
required.]. officers have exercised their 10.0 Electrical repairs or additions
t.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.❑Other
comp.insurance required.] -
my 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
tformation. -
tsurance Company Name: Pr •,,s C i t a` \ ,..1-SU C&(l Ce ,,i�
olicy#or Self-ins.Lic.#: \ I A' Expiration Date: c a — apt—)
)b Site Address: 3 Mar)v t-e a-1 1h A, c 3 AI\1 City/State/Zip: C3,�4,7
.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
'up to$250.00 a da against the violator. Be advised that a copy o f this statement may be forwarded to the Office of �,
- vestigations off the DIA for insurapee`roverage verifrca)on.
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to hereby certifynd ue`p4 a airs and penalties of p/e jury that the information provided above is true and correct
� y '
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?natu e "`^" / /1 ,ram Date: ( ! 3 i (? �'
one#: .Sf1•'n't- 777X
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 •
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:ontact Person: Phone#:
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