HomeMy WebLinkAboutBLDG-19-000293 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D RESIDENTIALO
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1__... .- INSURANCE COVERAGE
(kj I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. 142Ch. YES _/ NO 1
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND El
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 I AGENT El
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 complia e with all Pertinent provision of the
;Massachusetts State Plumbing Code and Chapter 142 of the General Laws. e14- v
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE#I 12298 SIGNATURE
MP 0 MGF® JP O JGF 0 LPG!Ej CORPORATION #I 3281C I PARTNERSHIPO4_ _ I LLC O# _ 1
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESSI8 REARDON CIRCLE I
CITY SOUTH YARMOUTH.. ,_ � , STATE MA ZIPt02664_ ITELI508-394-7778 _ 1
FAX 508-394-8256 1 CELL N/A EMAIL'accountspayable efwinslow.com I
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The Commonwealth of Massachusetts
u,> —. l Department of Industrial Accidents
_ ttol=a 1 Congress Street,Suite 100
!- Boston,MA 02114-2017
, •"'�t www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: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: Business Type(required):
1.❑✓ I am a employer with —10 employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.0 I am a sole proprietor or partnership and have no
7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers'comp. insurance required]**
4.❑ We are a non-profit organization,staffed by volunteers, 11.❑ Health Care
with no employees.[No workers'comp.insurance req.] 12.0 Other
*Any applicant that checks box 111 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#l.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:23 COMMONWEALTH AVE
City/State/Zip: CHESTNUT HILL, MA 02467
Policy#or Self-ins.Lic.#1821A Expiration Date:01/01/20/
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi , the ups and Iiialties o perjury that the information provided above is true and correct.
Signature: r "`'` �.� Date: a 3 j II r7
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.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia