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HomeMy WebLinkAboutBLDG-19-000340 5O MASSACHUSE T TS UNIF.RIVI APPLICATION FOR A PERMIT TO PERFORM OAS FITTING WORK ,„„utirs' CITY /�nN.#u.T� doh..,' ............... MA DATE .._7'?D—/I 1 PERMIT#,4A.417—R—C i 0 JOBSITEADDRESS:f d a! 6f.45,A✓T- ;v- a- C/rccOWNER'S NAME ' S''7 '12'• • Cotr7• t iii •• 1 GOWNER ADDRESS —�1�� ,_... .... ....... m.... ._m..W_.�..w........._....._. TEL„yet.7T`Jut;,...:FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL'_ I EDUCATIONAL ',`,., RESIDENTIAL PRINT CLEARLY NEW:': _J. RENOVATION: __I REPLACEMENT: „.;2d PLANS SUBMITTED: YES ..r.J NO _., APPLIANCES Z FLOORS--, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ... BOOSTER t_...._. I +. I . ...... ......f I 1- . .__1 CONVERSION BURNER I I' I I;• .........,,........._ z........... .... .. _....i._.._. . COOK STOVE 1_ __ 1___._.I I„ 3'.—_J._ j DIRECT VENT HEATER _ DRYER ,_,�__I�,. I ' . ... 1 -__I _._ I _ -I _} a FIREPLACE I . I. r __I I• _ 4 I I.„_4___I _i FRYOLATOR 1 ,___mi-*t I:.W..._.._.;_..__._ I .._Ji _.i.. ._ FURNACE i 1. I 1 .I GENERATOR ' 1 i GRILLE i._._a.. E .�..,.__I I ' I s I �� 3 INFRARED HEATER ._, ' . _ LABORATORY COCKS ,„I:____ -___._; ,�.. ` ,_.._i j-,..,.,,,...1,.-- I i ,. , MAKEUP AIR UNIT I j I !' . 1 I I I OVEN �,...�,,...,.. _ € _.I l i 1 Y '� _... POOL HEATER _ �i ____ r i; I I I __ ROOM I SPACE HEATER k _. . t I ---._ I I I € I r I___J I I_.._ I ROOF TOP UNIT 3:....... :... t... f . . .f - ._.I... ; I I -- i l ,.. _ - i I TEST 3 I_ __— 1 i i UNIT HEATER I_-._.__ :77 __,.... I —.._.J. ,if--.--:— - I' .. . I UNVENTED ROOM HEATER _ I ' ,_, ' I I _ I. I I_ ____i.____, _- I \ WATER HEATER ..... .... . ... . 1:-....._J. ._..__ _ ._ __ • OTHER I € � I ....... ._ �I~ E _._.._ . .�_"_____I _ ... l: I I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L.!„I NO . I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY : ,J OTHER TYPE INDEMNITY ,,I BOND I.,,,, 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 .._.:`: 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 compl• ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.& am j / PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW i LICENSE# 12298 SIGNATURE . MP %_ MGF _i JP ,.,_i JGF:__1 LPGI _ 1 CORPORATION i i# 3281C I PARTNERSHIP _:... # 1 LLC „j#. COMPANY NAME: E F WINSLOW PLUMBING&HEATING j ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH & STATE: MA (ZIP 02664 TEL 508 394 7778 I FAX:508 3948256 i CELL N/A _tEMAIL accountspayable@efwinslow.com tIS a 0 .§. t �� is Dc?-./a ri°'fr�% .i%d��1 ilY6?n27'ij grgei AlCCU 5i i. WI;il. ea 0 wasmr,dgioK3 r1 4,eG?(s l i i I ®gobs9 IV 02111 - wow.zaes2, ov/dit' . Workers' Compensation drmoulhrn coo Affidavit:iBalliderrs/Col trractt©rrsallecetrlei tng/PIl tmrtiverrs Ada li i t Information i'leasoyrrhtt Legibly Name(Business/organization/Individual): E,e. Vv w, .5(%Ai QL),6 the .�� Q0.1.d 1 v1C J Address: ikPuri C'ttaQ..- . _. City/State/Zip: �®v 114,'e ` wt,., C-Of Phone#: 50S- 394-117 Are you an employer?Check the appropriate box: Type of project(required): ,XI am a employer with 70 4. 0 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 7• ®Remodeling ship and have no employees These sub-contactors have S. 0 Demolition working for me in any capacity. workers' comp.insurance, 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.0 Electrical repairs or additions required.] I.❑ I am•a 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 12.0 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. 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 rormation. 44 tsurance Company Name: •.,� rtv -11 0-A (),2l el ✓1 olicy#or Self-ins.Lic.#: 1$ A 1 A- Expiration Date: C,—[ au-7 )b Site Address:,. ` May1 a--t T O -41l a`e 't4' r'M\ City/State/Zip: ( ,,L1 to 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 da a ainst the violator, Be advised t at a copy of this statement may be forwarded to the Office of tvestigationsi t the DIA for insurarpef yoverage veri`'oa on. do hereby cent un e e airs ana penalties o pe jury that the information provided above is true and correct. 64,,,,, iRnatu� • Date: [DIDI3 l I ra01 t,i hone#: .S,)S•. Vi - 7 7 7 X Official use only. Do not write to 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 Contact Person: Phone#: