HomeMy WebLinkAboutBLDG-19-006162 Cf
MASSACHUSE T TS Ui�IVFORM-APPI�VCATIOM FOR A PERMIT TO PERFORM GAS FITTING WORK
elt CITY JJ c: /l .G...- ......-._ DATE -z . .- - J i PERMIT# #4 _
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JOBSITE ADDRESS: �-..j• /yq r,C3voi -'lid d. !OWNER'S NAME 5 rivy Q QZ••(L
GOWNER ADDRESS '.`_.�.. ._-„i SY i✓.T3/7 - _ _ 1TEL /7 7/6eydi..wsFAX; �,.... �..�:
PRINT OCCUPANCY TYPE TYPE OR COERCIAL'I I EDUCATIONAL t RESIDENTIAL
CLEARLY •
NEW:' RENOVATION:U REPLACEMENT:''11r PLANS SUBMITTED: YES;_.:1 NO it
APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER r f, y; _i: .. --;-- i t; I: li I_____i`_.sil _ I'
BOOSTER r-•-1;---7.
-I_ .i - ;• - .• ' ..-..I .t "i . .._ •f - G, • -1-2 - _3I . -IF - --
CONVERSIONBURNER - ;-_ i -'!' i.w . ► _€ _._i. ..::I�_.w l 1 .^. .1', _ -g
COOK STOVE �.�,,., . I:✓ -..,.I.. .^ 1' t = i I ±,a, _j; . i',.,.__I_._i:._....J.��,...J
DIRECT VENT HEATER i I .. - .. _..._1: . ;
e• i:.. .!- _.. . _ 1,
DRYER - . .
tom,..._...:_.- -...:a.�,.,a._ .w.....,��!
FIREPLACE , _
FRYOLATOR
t
FURNACE _....
' GENERATOR ti
GRILLE i- 1..-.. , 1 ; . r,..,.� __. ...
INFRARED HEATER . __ ._ .
• LABORATORY COCKS ` - --
'.»-,._.I.t, ,..�, im,,. _ ...
MAKEUP AIR UNIT L ` I._ ! ££ ..._. [
OVEN II' .K1 , 1; I _ I i -'_._._I -i
POOL HEATER .I': I'.I ,. __ I, '': I,.I;____i!• . (:___ .__-•_..:
ROOM/SPACE HEATER "
ROOF TOP UNIT �-�-� R t_::. �..� �.-�. ... _ i��.�� --'
TEST • • • _-
UNITHEATER i. ;. ( I_: 1 1 I -. I I, t,,_ -�
UNVENTED ROOM HEATER • " -- •-1-.-_,:jr* - '` I._,--__ I-----
WATER HEATER_. ..........__.. - - -- :i 1
_:.. _I ---- .__---..-..Jr...-1;-"
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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 IA NO L i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY -m.j OTHER TYPE INDEMNITY J BOND ,,,-,I
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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 i....
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 compll ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. //f�
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW • _•• •• • 3 LICENSE#:12298 SIGNATURE
MP MGF.0 JP j JGF J LPG! 1 CORPORATION• #'3281C t PARTNERSHIP,,..5# • LLC .,. #.. _
COMPANY NAME: E F WINSLOW PLUMBING&HEATING I ADDRESS•8 REARDON CIRCLE
CITY SOUTH YARMOUTH - r STATE i MA I ZIP i 02664 {TEL'508 39-4 7778 I
FAX'508 394 8256 1 CELL N/A JEMAIL•accountspayable@efwinslow.com ,
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Depau°rpp g of beriustruggAccgaepgf
-4-,. r. Office offi vsstgoaaors
=u1.1. 600 i astingion 'Feet
- - I. ostoroy MA 02111
1www m agov/dia '
Workers'Conpeitiaat einIlimsuirannce davit:BuIl11aiQrrs/( mmtkrracttousfl Ilea i°ienaimsfiPllum bergs
L licantt on aattno» IPlea.se l�u tna>t]I,ebfi� .
Tame(Business/Organization/Individual): E,c.Wry i ov, 0,,,A3 tv L 0.e.�V,``n V�_ t elt o
address: tv c i � 0 U .)
;icy/State/Zip: 'Soo- ' Ycrv•-•,0,-,tin pule Phone#: '50N-39'4 P-1T7 l
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Nrre you an employer?Check the appropriate box: Typa of project(required):
I am a employer with "70 4. ❑ I am a general contractor and I 6. ❑New construction
.employees(fill and/or part-time).' have hired the sub-contractors
❑ I am a sole proprietor or partner- listed on the attached sheet.k 7. 0 Remodeling
ship and have no employees These sub-contractors have 3. ❑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
❑ 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' 13.0 Other
comp.insurance required.]
ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
iomeowners 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.
m an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site
formation.
IsuranceCompanyName: ,,,.s rt.1i-t10.)I ,r (t C ,V1L--)
rlicy#or Self-ins.Lic.#: r ' I As' Expiration Date: C---1 apt-) .
ib Site Addres03 Crtnmarl a-P-h km11 GR t'4 City/State/Zip: (:)„)L4 b7
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ' .
illure 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
i up to$250.00 a da a ainst the violator, Be advised t at a copy of this statement may be forwarded to the Office of
:vestigations o the DA for insurae overage ver 5 can,r
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do hereby certij,un e .e airs an penalties o pe jury that the information provided above is true and correct
i at& : AA Date: (oi.) 1
3( ad[ A
--4'none#: , Y•3giy-- 7 7'7'
c,
Official use only. Do not write in this area,to be completed by city,or town official • r,
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City or Town; Permit/License# ' c h
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector16.
6.Other
Contact Person: Phone#:
1