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Home My WebLink AboutBLDG-20-001552 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 .. r .. - k f CITY 1 j76(t21Qakti..--_... .. ......--.--.---._. •..-- --I MA DATE"_ql 1 ki ... .I PERMIT# lY 17 0. �� JOBSITE ADDRESS L.N.L,}.. J.e ti.. 5.4':.YYi(,!Y-!AA1°0(#...- OWNER'S NAME . . _ i a111tl1 C. OWNER ADDRESS ".--._. ._ ..._,SAI'1C'+.5'_--_._ .._____._-__-.__._..___. __ITEL1y).3- 71.S._7••3G.0.."FAX TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL[] RESIDENTIAL[ PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES ID. NOD. • APPLIANCES 1- FLOORS--I BSM 1 2 3 4 5 6 7 8 9 10 11 12 1 13 14 BOILER I I :1 1- lop� _. -iM- BOOSTER Wil�� ®� ��W(� CONVERSION COOK STOVE BURNER M' ;mums imm ] M� DIRECT VENT HEATER M�MMl��l��Mllllll®®®��1M®� � • - -_.__..i®._-.._.IMI[�M®[ I®IMIMM® DRYER MI��UMMMM®M FIREPLACE _ - ._!1__._ ._---i � ®® FRYOLATOR I=------'I�MCWi® IMM® I 1— -----_ !�� MI -._..II-._..._.I --... ..___..IM FURNACE r On V 't ) n '---...-� - ��,..._. _,�..._._. � CII-._......._IGENERATe' ..�:1- ----,GRILLE -_j_•—_-=MI® muIM!1.�� - - INFRARED HEATER � ��® ��®1 � �� LABORATORY COCKS 1�MmuM® MAKEUP AIR UNIT MMUMII ®MIMILINTINSIMMINI ®M ® OVEN -- -—-- WillMllE_Igri-Ma POOL HEATER - -. ROOM I SPACE HEATER I f�Im1W --- - i i IuMlEMMOI ROOF-TOP-UNIT-----------------—J--Li --:W �®�`��' _ --- --- ' �- ®TEST W UNIT HEATER MI MiliMIM EM[M— IWKWII�II �I UNVENTED ROOM HEATER MINIMA, ®®I®1® ®UN WATER HEATERI ®®M®®®®m®Mn OTHER .. . __ _,_ MI®®®® ..._.J®® ININNE - INI lVi INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES n NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY[1] 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. C , • CHECK ONE ONLY: OWNER LI AGENT Q . SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru nd accurate to the best of my knowledge SLR_ and that all plumbing work and installations performed under the permit issued for this application will be in corn ' nce with all Pertinent provision of the •Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / �� / ✓if-z „ PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW . . .__ _ . LICENSE#.12298... SIGNATURE MP 0 MGF[l JP[I JGF Q LPG!E. CORPORATIONQ# 3281 C.__, . PARTNERSHIP[ #" .. ._ . . 1 LLC o#I_ ._...- _. 111 1-s— COMPANY NAME: EF WINSLOW PLUMBING&HEATING ,ADDRESS'8 REARDON CIRCLE 1 CITY SOUTH YARMOUTH ._...-, STATE MA ZIP 02664_ yTEL"508 394-7778 :, __..__, _:!_ . , FAX I 8.394-8256 I CELLI NIA -EMAIL accountspayable@efwinslow.com • 66 bit, The Commonwealth of Massachusetts Ord 1, Department of Industrial Accidents Si 1a 1 Congress Street, Suite 100 1Boston, MA 02114-2017 _yye'. www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):E.F. WINSLOW PLUMBING & HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 El Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13•n ROOf repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other I52,§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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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 employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self ins.Lic.#:1909A Expiration Date:01/01/2020 k.sN"--...,_ 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 required 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. � I do hereby certify and ze pai s nd pen hies of perjury that the information provided above is true and correct. k � 0 Signature: r J / Date: Phone#: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.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: