HomeMy WebLinkAboutBLDG-19-004503 1 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
` ' 1 CITY IIIIM _ /, llili ,... _mar MA DATE,i.. . ,3.j j 9. PERMIT#M---/, /J-Od II iY
JOBS!I E ADDRESS .. I2 ..._...RA-t/Ll _.. . _..___-_.__._-..- OWNER'S NAME Qt'iyc .._.3 _ rry-. _
GOWNER ADDRESS - __par-1,1 E _ __ - - TELL Z:.3 63,_FAX - -
TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL 0 RESIDENTIAL[?
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:[j]z PLANS SUBMITTED: YESD NO0
APPLIANCES 7 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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INSURANCE COVERAGE
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have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES []NO LI]
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [l OTHER TYPE INDEMNITY 1 I BOND 0
(JJ 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 0 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 tru d 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 e with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. // 'J
PLUMBER-GASFITTER NAME_STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE
MP 0 MGF 0 JP Q JGF 0 LPGI❑ CORPORATION Q# 3281C PARTNERSHIP 0#I I LLC I I#L
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 1 508-394-7778
FAX 1508-394-8256. I CELL N/A ,,EMAILI Eccountspayable@efwinslow.com i
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Sa.N d 166. 6..+V1161/LV161Y6.666616 VJ 1Ia 64,0 O666U6.C1J
w_ Department of Industrial Accidents
1.4 °'M►=gri
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): E' . V�itr 5i 0 v [U •�6-kvAc �R -tc�I C .
Address: ' K •e cvi
City/State/Zip: Soo kv� kict-v..,a,,(-l•, r-iik Phone#: '50S- 39`1-117c
Are you an employer?Check the appropriate box:
Type of project(required):
am a employer with -7O 4. E I am a general contractor and I
employees(full and/or part-time).' have hired the sub-contractors 6. ❑ New construction
:.❑ I am a sole proprietor or partner- listed on the attached sheet.# 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.❑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'
comp.insurance required.] 13.0 Other
thy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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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
tformation.
isurance Company Name: Ant-0 i fl,p ck C r v,Iy
olicy#or Self-ins.Lic.#: \ $ I Pc Expiration Date: (— — D•C]
)b Site Address:D.3 G.vnr\crf'1 v•P0-41-N A ) CG,e3. t 11)` City/State/Zip: O ()
.ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ailure 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
f up to$250.00 a da against the violator. Be advised t at a copy of this statement maybe forwarded to the Office of
ivestigations a the DIA for insura •- 'overage verif a on.
do hereby certify un a to ams an/penalties o pe jury that the information provided above is true and correct.
ignatu?es
hone#: sjg.35`1 . 7 7'7�'
� Date: ( 1 l 017
Official use only. Do not write in this area,to be completed by city or town official.
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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#: