HomeMy WebLinkAboutBLDG-19-004228 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
tt CITY ,_ '_';AC.[ UL).;'^\ ( Pr, ") MA DATE �j 1 /()L o n PERMIT#I ,1-19 `1�
JOBSITEADDRESS 5c her)rcr - Lirc OWNER'S NAME Ralph Lnyun/o
GOWNER ADDRESS .C)A.n'►E_ _ TEL 6 1`I" i '" 1{I{151FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL El RESIDENTIAL[] "
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
1 ^ APPLIANCES 7 FLOORS--* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
^) BOILER L
L( ) BOOSTER . I I 'i
CONVERSION BURNER
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COOK STOVE
C—_ DIRECT VENT HEATER ,1
ti DRYER i, j
FIREPLACE I
n FRYOLATOR IiIiiiiiiIUhiI
FURNACE
GENERATOR 11111111111111111111111'
GRILLE
INFRARED HEATER
LABORATORY COCKS I' I,
MAKE
UP AIR UNIT 11
OVEN
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WATER HEATER ®MEI_'OM Min=IMOJ..ME MN MINI NM'NIB II�®
OTHER
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INSURANCE COVERAGE
,a I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES []NO [1
i I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
Cr LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY I BOND n
t) 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 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 tru nd 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 corn I nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
/PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 ' 47�SIG ATURE
MP 0 MGF❑ JP❑ JGF❑ LPG]❑ CORPORATION Q# 3281C PARTNERSHIP❑# LC❑#
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL NIA EMAIL accountspayable@efwinslow.com
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—*— Department of Industrial Accidents
ez
.2., Office of Investigations
n• j_iiiV= 600 Washington Street
% -- = Boston,MA 02111
s" www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information {{ Please Print Legibly
im
Name (Business/Organization/Individual): E.C• t,+�.5t0 Dw �t� Owic 2 0.e0-1-11 \ > VtC ,
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Address: F KPor,4cvi C;a
City/State/Zip: Sc,s din Ycro-,c;,,�-►r, C-NPr Phone#: `5O - 3T1y-1'77
Are you an employer?Check the appropriate box: Type of project(required):
am a employer with 70 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. I 7. ❑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 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 12.0 Roof repairs
insurance required.]t employees. [No workers' 13.0 Other
comp.insurance required.]
thy 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.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation.
tsurance Company Name: AYYO c\v 'o1\ 'L.. fCt&el(Ja. 0 �,
olicy#or Self-ins.Lich�.^^#: \ 7.a) A �a
Expiration Date: —] — OI9
)b Site Address:�3 `onno-‘c,1vt--ee..11 A-0-e C6e3 4. NI City/State/Zip: O01-I (o7
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
flip to$250.00 a da against the violator. Be advised t at a copy of this statement may be forwarded to the Office of
tvestigations . the DIA for insura -- ,overage verif .r on.
(
do hereby certify un e ze ains an I penalties o jury that the information provided above is true and correct.
i_ atuccr-: 4 ,1 ` i Date: (e. a aC117
hone#: ,.-n - 7 7 7 N
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
Contact Person: Phone#: