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HomeMy WebLinkAboutBLDG-18-007133 �� •� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -s CITY YARMOUTH MA DATE t1R/19/201R PERMIT#, D/TJ3 7O7/9 JOBSITE ADDRESS 17 SOUTH STREET OWNER'S NAME MURPHY,KATHLEEN GOWNER ADDRESS SOUTH YARMOUTH TEL 508-398-0761 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL l' PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED:YES❑ NO g 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 I SPACE HEATER ROOF TOP UNIT TEST 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[Q NO❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY[v7 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 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 complia with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE#1229 SIGNATURE MP vg MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION 12# 3281C PARTNERSHIP❑# LLC❑# 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.com WORK ORDER:475133 r5-0- �� t5b It Department opndustrwal Altccaaenrs - it 'ritidl;_ r Office of Investigations • 1- C: ,,,,.'_1.1=. 600 Washington Street -�• Boston,MA 02111 • '1/4« ii www.mass.gov/dia • Workers' Compensation :,Esurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 5Please Print Legibly Name(Business/Organization/Individual): , .\t�1✓�S I c vJ Q o ivnct ��‹Q-1� . clo,., l I( 0 6 Address: F Q, .zeatvi eira . City/State/Zip: Soo fIc‘ `lcrw,cs.A + E`-&P Phone#: 1.N,-`oq`'t-1`7? 'i • Are you an employer?Check the appropriate box: Type of project(required): , I am a employer with -70 4. D 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.❑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' 13.0 Other comp.insurance required.] lny 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. t tsurance Company Name: . 3 ,..3 \0 ni O.A ,.t;1'(T EA el C11. ce.," 1`-1 olicy#or Self-ins.Lie.#: l 7' l A- Expiration Date: k-`1 raot`7 )b Site Address:D 3 Cerivxmc.rn k,r c(JOh Au'e� ae..73 o h1 t \\ City/State/Zip: C3,•416 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 da against the violator. Be advised at a copy of this statement may be forwarded to the Office of tvestigations the DIA for insurape overage verir on. I do hereby certify unnc elr e ains ana penalties o pe jury that the information provided above is true and correct. I Ar ignatuLr : L"" ! /t Date: (D 31 r^,�©k hone#: ,S11-3`t`i- 777s Official use only. Do not write In this area,to be completed by civ or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.ElectricaI Inspector 5.Plumbing Inspector 6.Other . Contact Person: Phone#: