HomeMy WebLinkAboutBLDG-19-006689 O
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�.e5 it 5 CITY Yee,QI& MA DATE 5/2,.0 /q PERMIT# Ot-1Q—Od CPS
JOBSITE ADDRESS 31 Itjedrat PJ WCS} Yar,n40 ,11 OWNER'S NAME Ulna k-rne(
oarys
G OWNER ADDRESS _ S hme TEL $ i 1 l 4 cb i% FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL[1 EDUCATIONAL❑ RESIDENTIAL[]'
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑' PLANS SUBMITTED: YES[11 NO❑
APPLIANCES 7 FLOORS--4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER 11U111111111LDIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR I.
FURNACE i I!uiiPiiiILIt
-
GENERATOR �� r 1111111111111 II
,,, , , ,
GRILLE III ��
LABORATORY COCKS
OVEN
POOL HEATER
ROOM/SPACE HEATER TEST
UNIT HEATER 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 [1]NO
El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I ' I OTHER TYPE INDEMNITY rj BOND U
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
r4 MITI
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
5- ,......V." il 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
Vs Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '
rite" a
a PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNA URE
J MP 0 MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION E# 3281C PARTNERSHIP❑# LLC❑#I I
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 1508-394-8256 I CELL N/A EMAIL accountspayable@efwinslow.com
I� &.1... 6i i10 0 6006C/O6 I V 6.666606 lid AI_ 60,9J 666.O6 04,,6.66JD r
Department of Industrial Accidents
-i,: Office of Investigations
. _ 600 Washington Street
''_ Boston,MA 02111
5, v0 www,mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): E.'f'•1. ,As(0,,v ,0,.,tp„Aj. L kl.f e\--"ci Cz.,, ((-I(
Address: d
City/State/Zip: Soo -i,"‘ kicr-o-,0J-t•, M Phone#: '508- 3911-1'V1
Are you an employer?Check the appropriate box: Type of project(required):
XI am a employer with `70 4. ❑ 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 _- ' r 7. Remodeling
or partner- listed on the attached sheet.- L1
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 11.0 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'
comp.insurance required.] 13.❑ Other
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. p
tsurance Company Name: YYtj�. �1, �-tic f( ��q OVTA,,i ce. 00.1,,,,itvi--)
olicy#or Self-ins.Lic.#: \ $a l A Expiration Date: (_ — aoi9
)b Site Address:,:).3 G}'Mrvevl v,,ec-1 1 C6e31411s NI City/State/Zip: d,)t-I b 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 tI at a copy of this statement may be forwarded to the Office of
tvestigations . the DIA`for insura ,- 'overage verif on.
do hereby certify an e ze ains a /penalties o cr
jury that the information provided above is true and correct.
i_natu? : / -41111111116.- Date: (a i ao i7
hone#: <I>X;.Z5 y 17 7 7E
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
Contact Person: Phone#:
1