HomeMy WebLinkAboutBLDG-17-001377 &. - , 1((
i MASSACHUSET T S UNMFORIVM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY S'd 4/I�f�' . iy1 yyay2'// !�: MA DATEa e'2 !PERMIT#/8406-i`qC✓7 7
JOBSITE ADDRESS 7 !{ ,(,_ i- cif 71 OWNER'S NAME - /i._-c f G c'L-<1 c t 1,
GOWNER ADDRESS I,,L,i tL iT %CF1�,( )& ✓[ ;c1�u(ay TE -1-,F•7‘iet6 iFAX I
TYPE O OCCUPANCY TYPE COMMERCIALS EDUCATIONAL D RESIDENTIAL 1
PRINCLEARLY NEW:1_1 RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES 7 NOLj
APPLIANCES 1 FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I _
II .. �I ....i� I ... _..11_ 4i. ... .li I: _. .._�I _i_.... .. ! i{... + G
BOOSTER I "I 1... _ .`I. . FL..: i .II 71 11 . I I I.. 1L (I 1,
CONVERSION BURNER ________(11. r . .i-.- l_ i ! it � .— ;!_ if-. fl _il I �I�s
COOK STOVE -_ , __ _ _i-- c_1 _ .- L� _,+ Il I 1 —J_ I_ --
DIRECT VENT HEATER I.._ II. l
I _,Ii:7... I--DI-. .`?i ,1. .11 ...'1__.. . 1_,_ _f.l, �k1j=., 1f77_ 11, -.... .
DRYER 1 f ! - •. 7
FIREPLACE Cr.:, i. _�.1 --,;-T_al--t! - '! �g._ 1----11-----il 1 I!-;.... 1
FRYOLATOR III I'.--_1 ET.---,_I I i sl 1� �I.._-_I—_11_:__;I _!L. -1(�f
FURNACE I. !I.� :il. 'I_ I'I el ,.. -11— i^ 1 -1 ;I I il_ fl�f -
GENERATOR I _ _h. 1- 'L. .. 'l _,: _-II. _.II... .II1 ''..... --;1 .-1_ _`i_
GRILLE 1 1 I I .11 i _ UII .I 1 j•;I (I— i I a i
INFRARED HEATER I_. ;L .vl." L _si ._ i.. `I I L . ! .I I_ !
Ih,•LABORATORY COCKS I. ;!.-. . 'I I_ ' l' II i .-_..11-..._. I I ii. :11 +1
c MAKEUP AIR UNIT I_ l! .:1 i . 71I , _ 1 1' il_ 1(�� i _ I I i 1 F. __
OVEN L��.II !1 `1.. cl tl s' it ll 7.117 TT177H, 1(.M! I
OOLHEATER 1r._— I' . 7I I. :l_.. `1 ._—i .11 .—:II. , '!, 1- ,.11� il.— ti ii
ROOM/SPACE HEATER L F I.....-{i__,-•...,1I,,, C _I I,. .-`I o I ti I _. I _ . ..
ROOF TOP UNIT L_._:I.
r . ,(— ;1.
II— 1 I . I 1i.. . .I I 11. .-I I . 1I lITt
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TEST I,, I I I- I --'I i "ill... �: I— ,1 :I!i`—k ED
UNIT HEATER I l .iL '.L.F 0 ,l_. . . it .e h `�I 1, I C
UNVENTED ROOM HEATER I^_I I.. ._a _7, l — 1 . 11 'L-.-_ 1 . ..II_ r 1,_-31_ L_ !
WATER HEATER 1 'I .. it .. it I —A
'I y1 ! _..177 d
OTHER I ----_ i l._._ 1 I.._.. 'I_: ...1� I .._ I ... -1
'� 'I I I •I I 11� if----(1 1.
1T — V .._. ,�a.._.____.. - . = ,1 'I. _ I Lt.-7
_:I:---=;1. 0 I i I 1 _ I! "4I !I- 1 I _
' .;CT`.,7 f T, E.T-1 �. l r--. .'l..__,,1•v ,I�.,2[.r.:._i! �1�.---.'
1 r INSURANCE COVERAGE
I have a current liability insurance policy•or its substantial equivalent which meets the requirements of MGL.Ch,142 YES Li]NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1 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® AGENT 0
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 comp! nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 02,14,c,-egi-k./
PLUMBER-GASFITTER NAME STEPHEN A_WINSLOW ���1 LICENSE# 12298 y SIGNATURE
MPS; MGF D JP I-J JGF E LPG!El CORPORATION;#_3281C li PARTNERSHIP # ;LLC�#
COMPANY NAME: EF WINSLOW PLUMBING&HEATING 7 ADDRESS 8 REARDON CIRCLE i.
1
CITY SOUTH YARMOUTH � STATE!. ,ZIP 0266� 4 TEL 508_394 7778 _ __________
FAX 508-394-8256 ii CELL�`N'I"A"—� ;EMAIL accounts a able@efwinslow.com _
a-
— Depst.°imept of JDed/str/vil A!I crwer'is
' u Office of investiga.tions
. 4, j
r. 600 Washington Street
�� Boston,MA 02111 •
O www, nss,gov/dia. '
Workers' Compensation Insurance Affidavit: Puilder°s/Cormtractors/Electricisns/Pln i'bers
Applicant Information Please Print Le bly •
Name(Business/Organization/Individual): .c.kAl 1'AS 1 ovj Q(V o w'cj .2. VI t�\--I , Qs_ 1 vtC o
l
Address: (?a tt3n C tm . _
City/State/Zip: Soo-V\ Yc 'v•-•1c,..41n MP Phone#: S'US-.3c14 -11?C1
Are you an employer?Check the appropriate box: Type of project(required):
.. NrI am a employer with `7O 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 ? ❑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. [II We are a corporation and its 10,0Electrical repairs or additions
required.] officers have exercised their
i.❑ I amna homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions .
myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
. insurance required.]t employees. [No workers' 13.0 Other
comp.insurance required.]
1ny 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.
lm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1
rormation. { ('�
isurance Company Name: c�\Y y..,s ( i t•t/aA S(1�2,t el C.Q. \ nl> '0l
olicy#or Self-ins.Lie.#: 1 -' 1 A. . Expiration Date: c.--I — apt—)
)b Site Address: 3 G.rv,r-kUn\ P o }i-a, ae'\ I n I\ City/State/Zip: O)s-1 to 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 d ayagainst the violator. Be advised t]I!t a copy of this statement may be forwarded to the Office of
tvestigations the DIA for insurapefoverage ver i can •
on.
do hereby certify un e e ains anti penalties of' e jury that the information provided above is true and correct.
i ahue:- L._ / ,sue Date: (c1-44! 3 i 1 a0[��'
hone#: .0 •?)riH' 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 .
7.ontact Person: Phone#: