HomeMy WebLinkAboutBLDG-20-004200 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
a.Y= t
_: L = -�-�- PERMIT# l�i�O_L (#7
MA DATE j � '
e 1=iJ CITY `.__
•n OWNER'S NAME
JOBSITE ADDRESS ��//
TE 4 [�+ FAX
G OWNER ADDRESS n�,�I11 ptj VR [-IA I ev)/ilr
TYPE OR epi OCCUPANCY TYPE COMMERCIAL EDUCATIONAL L �� RESIDENTIALP___/-
PRINT
CLEARLY PLANS SUBMITTED: YES Li NOL...,
NEW:(� RENOVATION:L. ! REPLACEMENT: -�
APPLIANCES 1 FLOORS--� BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
�o BOILER -i
( I '
i BOOSTER � i __ - , ( 1
CONVERSION BURNER I i I 1-_-__-._i_.__... _
.M.I...__ . �. 1 1 _.._
COOK STOVE ! i I l -1 1 I T
r
DIRECT VENT HEATER (_ !_ I� I� _-I [ '�-
1 I-__-- IL II _ 4. i1 L L:1- .- .
DRYER I MN.( '�- L I il� i� L_ - r._ _,r��r_
FIREPLACE _
FURNAC OR r- L` L.., L- C JL L .J 1-
Im ..4 (- ice _
FURNACE I-- I FT:1---1 .. ri :L, i -
GENERATOR I
GRILLE 1_. I
INFRARED HEATER I �aL. _ L L r L._, ,I 1 _.ew I [ 1_r 1 ._
LABORATORY COCKS _._ J L . '_--�=Li- _ - I r .
f,.__._I1 ;C.�: .sir. .� .j : :.. 'C
MAKEUP AIR UNIT I __ ---- tf Lm._-
OVEN - -�1 �`��hm_.�1.�..�_.i.�..� � � -I� ��
POOL HEATER - �l 1' 1 aL I -
L f
ROOM I SPACE HEATER I ( _ ( I__r-
ROOF TOP UNIT I e - ,1 {L—
�;' 1110.1.11111101111.11.01.011.11111
- 1 -
UNIT HEATER T I_I_Mi I INII( G.-- I_.liM .. ..J_ -__.s I I ,.
UNVENTED ROOM HEATER I, IMAM �' fillia
--, If, L L
WATER HEATER -- ' - r- h I� ,ECF .
OTHER I - ' I I m r .
I _._ - I I r.
L :.1T1_ . 1�- 1 r—1—1 i
�.. 'f� INSURANCE COVERAGE
t I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [7,1i NO [-II
S. I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY 111 BOND I_;II
OW
NER'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 Ti AGENT LI
SIGNATURE OF OWNER OR AGENT st of my
I hereby certifyllplumbing all worthe k andetails instala ind nnformation I have stallations performed under the submitted
permft issued entered regarding
this application application
will ben compliancand
a 1 aat[to the
rtine b provision of the
knowledgeand that all Y, ......�^—,..-
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I STEPHEN WINSLOW I LICENSE# 12298 # SIGNATURE
MP MGF® JP 0 JGF El LPGI0 CORPORATION LI#13281C I PARTNERSHIP LLC
#
COMPANY NAME:I E.F.WINSLOW PLUMBING&HEATING I ADDRESS 18 REARDON CIRCLE I
CITY I SOUTH YARMOUTH I STATE l MA ZIP 02664 —�TEL 508 398 7778
FAX I 508-394-8256 I CELLI N/A (EMAIL INSPECTIONS@EFWINSLOW.COM I
/-71- 1y A.
The Commonwealth of Massachusetts
_ �= Department of Industrial Accidents
Office of Investigations
t, W+ Lafayette City Center
2 Avenue de Lafayette,Boston,MA 02111-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
licant Information
Please Print Le ibl
asiness/Organization Name: E.F. WINSLOW PLUMBING & HEATING CO, INC.
Jdress:8 REARDON CIRCLE
ty/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778
you an employer?Check the appropriate box:
el I am u employer with 9v Business Type(required):
employees (full and/ 5. ❑Retail
or part-time).*
] I am a sole proprietor or partnership and have no 6. ❑Restaurant/Bar/Eating Establishment
7• El and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
] [No workers' comp. insurance required] 8. 0 Non-profit
We are a corporation and its officers have exercised 9.
El their right of exemption per c. 152, §1(4),and we have Entertainment
no employees. [No workers' comp. insurance required]** 10'0 Manufacturing
] We are a non-profit organization, staffed by volunteers, 11.0 Health Care
with no employees. [No workers' comp. insurance req.] 12.0 Other
pplicant that checks box#1 must also fill out the section below showing their workers'compensation policy information,
corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
ation should check box#1.
!n employer that is providing workers'compensation insurance for my employees. Below is the policy information.
nce Company Name:ARROW MUTUAL INSURANCE COMPANY
•'s Address:
ate/Zip:
ft or Self-ins. Lic. #1909A
Expiration
a copy of the workers' compensation policy declaration page(showing the policy number0and 0 expiration date).
to secure coverage as required under 25A of MGL 152
10.00 o and/cov one-year § c. can lead to the imposition of criminal penalties of a fine up
e ear as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to
la day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of
for insurance coverage verification.
eb1'Ce� �/tef the ins and penalties o perjury that the information provided above is true and correct.
cer �F/ .fp J Y
1
01/02/2020
508-394-7778 Date:
zl use only. Do not write in this area,to be completed by city or town official.
r Town:
Permit/License#
Authority(check one):
)ard of Health 2.0 Building Department 3.0 City/Town Clerk 4.['Licensing Board
Aectmen's Office 6.DOther
I Person:
Phone#:
www.mass.gov/dia