HomeMy WebLinkAboutBLDG-17-002890 \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM OAS FITTING WORK
__ CITY _ _ - __ MA DATE )Lint) �, I PERMIT# �'I7 DGbl % D
JOBSITE ADDRESS q 4 j Q.f�^l i OWNER'S NAME a. d -_
GOWNER ADDRESS 7(_, CELC ~i ( 7EI _ gFAX1_ _
TYRE OR OCCUPANCY TYPE COMMERCIALLJ EDUCATIONAL® • RESIDENTIAL
CLEAELY NEW:j li RENOVATION:I1 REPLACEMENT: 'ILA,--- PLANS SUBMITTED: YESD k0 E i
APPLIANCES 1. FLOORS-> BSM 1 2 Emus 6 I 7 8 9 10 11 ® 13 14
BOILER 1[ .i 1:` ®Emususus
BOOSTER - I_-1®®®®SJO ®MENINEMINIE®
CONVERSION BURNER Ir.. I IV._ 1L- ,:I,..._ {_.._ = _,i���® ®`� N
COOK STOVE 1=•:- I I -..11__.,1_-.�.-1 _i - ?..`;..vJl.-Iiiiiiiiii.®®®iiiiii
DIRECT VENT HEATER I_ --I I___.___1 17 I` ._f 1- ___'_ .-1 - ®®MI�®®
DRYER i. 'I- ,I E___J`- -11„ --`- _ .t , _[I_,:_.Ii` ,i I _` I. I`_,�_(1l.1_,_.i
FIREPLACE Li:. ;I.- -' - -I}• - i. -I - .,iw--•.�, •- _'I
FRYOLATOR • I i I.. _ I' ..=ri1. __ (.- . J ._ i .; I. _�I__w:31.--il--1 1_--_- --'Li .
FURNACE 1..... I I H{ . .. L 1 •I. --��usus®®us®®
GENERATOR L 'rl_ [- E.. .;II:_.-(-,i. .-__(®®�®®�_ ®us
GRILLE i-M #I„ I'I.. ` i ,1� ;i.__ ,I I. _I 'I. _-�-. 11. I _Sf
INFRARED HEATER 1_,, ,1:1_ (, -I-_;i_7 'i^--`I7-i{-"." ;1�• i. .__`1� {I^T_;I y _ I. �1-J
LABORATORY COCKS I.. iI- 1 i^-;I_ I 1 ., ,,i I. -._ 1-. 1-._-( �(1 I—I
MAKEUP AIR UNIT 1�(-U.___,I.. (I .-,.,sl:...'. _+,h..-_i®®Emus®us®®
OVEN us®®usus� IMuslus®Em®®ON
- POOL HEATER 1,_____;I,..,...J I . ....I i„T I-, Tit ,.---.a �!.-- -I -�(-....I.---. .I I�. !( - (I. ..
ROOM I SPACE HEATER (.�tl ,._—JI_._-._pia ri._ _-`I(-,-_-1 ® i_.. :{ ,_.,_(I ,.: j1._.._.11--,— ,_1
ROOF TOP UNIT _11_. .11 �Il_- . ;. Il Am._tL ►L,- I...._., IL.._. _.IL,KI. , 1
TEST 4____:1 , - , T --L•• 11. __ ._ ' --17.-, S I I III._.,_ I
UNIT HEATER r` " I=: .1-.L-I,I.___II ,iII �, �`1--11--_.,I-m1 11�.. in il_ .
UNVENTED ROOM HEATER MI. ,I I f I:_. ®®us®us®�®
WATER HEATER- - it i~f�l.. II__Imi®®®��®®®
• OTHER _ IC,~_ l I(= r.: 41,.__ ' •--._.;I._, ;I._. `I.. '1�---.II_ _ I1 7_11._. .,l[-.-.I
I_T ---��—._ _- — 1, _�I�• �:<._— l_ . 11; =j1 -J - y}Ie__:_.I(„ ii II - >,1I.. _ :Ir !____.
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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 E NO ,i
• I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
' LIABILITY 1111URANCE POLICY OTHER TYPE INDEMNITY Li BOND
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have theinsurance 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 L-j AGENT U
SIGNATURE OF OWNER OR AGENT
I I hereby certify that all of the details and Information I have submitted or entered regarding this application are true a '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 compile):with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME S T EPHEN A.WINSLOW I LICENSE 412298 SIGNA E
MP LZi MGF 0 JP 0 JGF D LPGI jj CORPORATION U# 3281 C M.. 1 PARTNERSHIP Al D j LLC #
• COMPANY NAME:IEF WINSLOW PLUMBING&HEATING `ADDRESS 8 REARDON CIRCLE_LL-_u4
CITY SOUTH YARMOUTH . __ -, •' STATE MA ZIP D266 1 I EL 508 39^7778
FAX[508-394-8256 1�CELLrNIA 11EMAIL accountspayable@efwinslow,com
marf Boston,MA 02111
�,,,: , www.fflangov/dia • �'' .
Workers' Compensation Insurance Affidavit iIders/Coatrractorrf ectlricians/Phuu nlberes
Applicant Information Please Print Legibly ..
Name(Business/Organization/Individual): �=c^• idtS� U # �4.0_t7,nrl, 'tips-i 1,r-iE ff
01
rm
Address: g' ,eurt t, ti: . .
City/State/Zip:. So-,I f Yc<r ts--Lo,,,-t H.Pf Phone#: ?S-3 9, 'J' n • .
Are you an employer?Check the appropriate box: Type of project(required):
jI am a employer with `7O 4. [ lama general contractor and I 6 0 New construction
.employees(full and/or part-time).* have hired the sub-contractors
;,E. I am a sole proprietor or parter-
listed on the attached sheet.? 7• El 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
I.❑ 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.[Roof repairs
insurance required.]t, employees.[No workers' 13.❑Other
, comp.insurance required.]
Illy applicant that checks boxnl 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 checkthis box must attached an additional sheet showing the name of the sub-contractors and"theirworkers'comp.policy information.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
'formation.
isurance Company Name: ��0 {'i�t unit tSLKre. A .. 00. , t:�IL-3 ,
,
olicy#or Self-ins.Lie.#: li T a.i - Expiration Date: c---1— au—)
)b Site Address:�3 � W u J i i, A3`?, ;-1E .l r11 City/State/Zip: Or)q(67
.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 MOL c.152 can lead to the imposition of criminal penalties of a
tie 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
hip to$250.00 a da against the violator. Be advised that a copy of this statement may be forwarded to the Office of .
tvestigationshe DIA for insurarpoverage verirn.on. t
do hereby certify uncle he ains andr penalties of pe jury that the information provided above is true and correct
5 i
iguat rei,-..._.w.---_-•- t'' /1 ,s_et Date: cz-=;3 i { '0 t "r+ 1
I
hone#: .((pit-' ` '-77 X
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.Electrical Inspector 5.Plumbing inspector
6.Other
Contact Person: Phone#: • .
I
•