HomeMy WebLinkAboutBLDG-16-004260 .a. . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�_ l PERMIT#M--P6--- ,,�-00.404LCITY LL MA DATE i�, I f rr tt
JOBSITE ADDRESS i y3,- I ROL—e .2 ' n�nc4 10r,OWNER'S NAME OI yr p j a, r1; 1 I-1r l cr . _
GOWNER ADDRESS 5 A►y)r 1 TEt;SQs-3 .- IA` FAX
TP PETR OCCUPANCY TYPE COMMERCIAL t� EDUCATIONAL-1 RESIDENTIAL;,
CLEARLY NEW:[ RENOVATION: i REPLACEMENT:f PLANS SUBMITTED: YES I_ I NO[ 1
APPLIANCES Z FLOORS-0 BSM 1 2 I 3 4 5 6 7 8 9 10 11 12 13 14
BOILER IC
BOOSTER _}r ..i
CONVERSION BURNER i
COOK STOVE u 4
DIRECT VENT HEATER
DRYER _
�IY�Lq
'w'- f i-LACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
f_
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
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TEST It _
UNIT HEATER _.
UNVENTED ROOM HEATER ,.j i.
WATER HEATER _ I .=I t,
OTHER _-
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1 ' I OTHER TYPE INDEMNITY I._! BOND L 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 (.j AGENT LI
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 compli ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - ^
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW 2.LICENSE# 12298 SIGNATURE
MP Li MGF Li JP Li JGF® LPGI Li CORPORATION[J# 3281C, _1 PARTNERSHIP®# ' LLC❑#r
COMPANY NAME: EF WINSLOW PLUMBING&HEATING 1 ADDRESS 18 REARDON CIRCLE 1
CITY SOUTH YARMOUTH 1 STATE[ MA jZIP 02664 --1TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL accountspa able@efwinslow,com ,_
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S \ A ILL <+v.....cvrc rrLwbt rs 11.1j u MO uu..rs YSJl.L1,
Department of Industrial Accidents
„Tt= t Office of Investigations .�
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600 Washington Street
* ='l3i1= a Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information E Please Print Legibly
Name (Business/Organization/Individual): 't'�-•W�,n510o/ Q(V v,AIO waccl ,e pL n d•\c _ ce
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Address: F Podct✓) d
City/State/Zip: Sc.s Ycry ,(,.,k (fir- Phone#: `5O8- '394-11?
Are you an employer?Check the appropriate box: Type of project(required):
id I 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. t ❑ Remodeling
ship and have no employees These sub-contractors have 8. [' Demolition
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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 11.0 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.❑ 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.isurance Company Name: AYytt ,.),. C jli CtA l -s'u.,t,n( C 6-1,v yt 4' j
olicy#or Self-ins.Lie.#: $a I Expiration Date: ""?
)b Site Address:.)3 r40✓1v'-e0--1,11,N C t'1)II City/State/Zip: O,)a-i (c 7
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 day against the violator. Be advised tljat a copy of this statement may be forwarded to the Office of
tvestigations the DIA for insurapetoverage verifation.
do hereby certify un a /e ains an penalties o pe jury that the information provided above is true and correct.
ignature: ; , Date: [a 31 1 ao l
hone#: (:)T%t( ' 1`t -
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#: