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HomeMy WebLinkAboutBLDG-17-003381 • MASSACHUSETTS UNIFORMi APPLICATION FORA PERMIT TO PERF*eM GAS FITTING WORK \\\ ; CITY plcrol\Lrh C So MA DATE a``(CIPERMIT4'f)-Pb/7 -ow 3 4/ 4 i , JOBSITE ADDRESS _R/7' ` , ,OWNERS NAME - GOWNER ADDRESS !fL .1 _ X r'" ' f IEL � 5 ,FAX 1 E° OCCUPANCY TYPE COMMERCIAL] EDUCATIONAL rj . RESIDENTIAL FERNIT CLEARLY NEW: `D RENOVATION:C] REPLACEMENT:0 PLANS SUBMITTED: YES[ Nod APPLIANCES FLOORS BSM 1 2 3 s l s l 7 a s to 11 12 13 14 BOILER II •tl11_ `C _._1I— t, Ii_. Ii.7 —Ili li -Ii Ti,...---Il..__J BOOSTER • I-._--r-I E.__ I I�_ I.. 'I� ..i__,1 .._j(__ _ �`--1 . .,.rs ;I E1: ..t11_~I__AI_ I. CONVERSION BURNER I jL._ I.: :l:_..-.- 1J_ ;I -_ . ..tl- Ii .. il___...,II7.i(_._ -11... ,__i__.__-ll. 3 COOK STOVE IT )1... .l1-_. '1 __,.1I _.('-__. .4,....1 I� 1 i ._. .. (1.�-1 I. . I 1771 - - 1 DIRECT VENT HEATER I }ii_ --(Ir (i ..fl- C�`"�I;,`-"I`y__IC--- ;I_' � (_ 1I�. _,fi .iL—• - DRYER I i �:—ir_ _�11-�..-11'% i rIr _-'I .11. T_1 _ 'Iy :t1. 1--=..IIr -.II!r..:. v. FIREPLACE l _, I _Al __I: . .-_-=' 1.. _ - s_ _ L.. FRYOLATOR it1.. _;1 ..._1..JI.. II- -11_,... 11.,_..-. 4.. . 7.--.11, ;1 ll__ ..i FURNACE -I (I _-. �L - - t1- - 11. .r.l_.-, '•I.__1i tET'i.~ 61-._..J- __II_ '-_IL.—.l;I. - . GENERATOR rl= �'� __I---,,----,—„—,______________ ___^ ( tl __( II •I_ r!_ 11_._ 11^ '�1- i_... GRILLE �'tr_ - _ _ I .�i_._:-.t ,11-....'I.. .t l. . ._.i 1_. i i.,_ii '1 -,..I I( _ t ____( - I I -i INFRARED HEATER _ 1 ( _ -- LABORATORY COCKS • i i�_.-_,i^�11_ . 11 i' ;^ - -t ! MAKEUP AIR UNIT . • I E1--:1.___II_ (I ..,,L:...'. -11,..__tl1E1 I -1 'I IfII II,, ITII..,.,. ----.. !..._IC. i1- - 1'--- • `1- . . .►1� J. v.}I-:._.. [I._....!I77.k17.7. ' OVEN � -_ •__.._•_. . .. - I:__._.t1-=.t1._. :CT).._. .il. .1L 1L i _ - POOL HEATER 1--�'I,.,.,_.,l l .....I f,,Tl I_-._ .k.�.=_ .. _. _ .. I ROOMISPACEHEATER I—,(r>-__JL-..__J ,. L.-_-r'(-._-_11^Six il._._:,,SIT_ I, 1IL... II..._.11., JL i ROOF TOP UNIT 1----JL._►I. Il-. ..11.-' ' -_ 11 I,.71 fl_ i1. ;1...._,_11.. , . tt_,v1�J TEST I____: ,r-..:1-_:":"1- -�1rt -.RI. Jti_. _ 'L __E(.-ll.�_ t-. _ l=, -ILr. I UNIT HEATER _- .. 1-.y .I. . k . _.tC_ 1 _ 1 ..,,_ir. ,;1, -.I - -`1 1-.._ `I. 11-._-.. UNVENTED ROOM HEATER I_.-f1-t,I . _,II--_., S ll�:._nl: -ll__ -. I'1.- Il-«._,(�I,. .11=,_''I.,- I�1 ;t1-1C I. L�I WATER HEATER y• tl�;lI tl_. .l ._. il,_ . ,li JI�-I OTHER! II _1 ,31_. ..ice G _ `1. 'I-_ -11- .;I. '17-1= .11_ ___fl_-=11._._,I;I..,_._..1 I .i Imo.I �-.�__ ,..J r'�� .,. lT 1.- _-_ __________2_ i„ _ .. ---.-1--.-. (II—I _- -(-- .1I :-.1 'I•- .7i, -!I_._ .JI.. .._'i-,.`.1_ _ - _�.- INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL,Ch,'142 YES El No L • t iF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Lfj OTHER TYPE INDEMNITY 0 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 0 AGENT C SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details end information I have submitted or entered regarding th s 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 comps nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. •4 PLUMBER-GASFITTER NAME S T EPHEN A,WINSLOW 1 LICENSE# 12298 SIG ATURE • MP LI MGFD JP 0 JGF f LPG]D CORPORATION F<#[Etc__ PARTNERSHIPL 1 I LLC U# • COMPANY NAME:tWINSLOW PLUMBING&HEATING ADDRESil S 8 REARDON CIRCLE : ________ CITY SOUTH YARMOU T H _.,�� 1 STATE_si . D2664 1 T EL 508-394-7778 ' FAX 508-394-B258 CELL NIP, _ _1;EMAiL accountspayable@eiwinslow,com _ ' l )1(6, - 767 ‘.i 5-6 it) o 113 Yr-73q 3 e_2 Workers'Compensation Insurance Affidavit:Builders/Contractor_rsrlechrdcians/ °llumberg 'Alp"lizard I[isforxmation Please Print Legibly .- \VsrS0Q Name(Business/Organization/Individual): , . Jtvi liNS. Vnei . r ,r . ciA_ (,1-}1',a 0 A .dress: r q4 r; Q • . .. . . City/date/Zip:. c c c d Phone#: °t`r `7 . Are you an employer?Check the appropriate box: • Type of project(required): „�.I am a employer with `7 4. ❑ I am a general contactor and I 6. 0 New construction employees(full and/or part-time).* have hired the sub-contractors I am a sole proprietor or porter- listed on the attached sheet.? 7. ❑Remodeling ship and have no*employees These sub-contractors have 8. [Demolition working for me in any capacity. workers'comp.insurance. . 9. D Building addition [No workers'comp.insurance 5. E. We are a corporation and its 10[�Electrical repairs or additions required,] officers have exercised their 1.0 I am ahomeowner doing all work right of exemption per MGL • 11,[Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and wehave no 12,[Roofrepairs . employees.[No workers' insursnsequsrad}`. —---— - 13.❑Other . comp.insurance required.] Iny applicant that checks b6x#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 anew affidavit indicating such. lontractors that checkthis box must attached an additional sheet showing the name of the sub-contractors andtheir workers'comp.policy information. . am an employer that is providing workers'compensation insurance for any employees. Below is the policy ant/job site i ormrition. _ isurance Company Name: �.,0 ( J S rt i~ira el cit,-Ii, �y • .olicy#or Self-ins.Lie.#: 1 a - • Expiration Date: [-I e�f.�'t' �b Site Address:?3 'V\1'''�'c ice, r 3 , Ct-,ezk to 1 �1 City/State/Zip: O,�) .loch 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 o.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 dday against the violator. Be advised.that a copy of this statngn ent may be forwarded to the Office of westigaons he DIA for insura� e1overage veri c on. • jti do hereby certify un er4e t ains am fpenalties of perfiaty that the information provided above istrue and correct. '': 7 I `j : ianatu e; __ "t"" n Date: (`ot_g,3 1 � hone*: . ('iA l i , 17 X Official use only. Do not write in this area,to be completed by city or town official . City or Town; Perrnit/License# Issuing Authority(circle one): • 1.Board of Health 2.Building Department 3.City/Town Clerk 44.Electrical hnspector 5.Plumbing Inspector 6.Other • • Contact Person: Phone r: . •