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HomeMy WebLinkAboutBLDG-20-002889 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t• ,. - CITY YafigAS1 .._._._. _. ._i MA DATE[ ig_l_ 1'1....._ .1PERMIT# / 'Oa JOBSITEADDRESS 2-1Cq•pfl.V\. Cjai,,Ac.Rd 51 U1 0.i'! OWNER'S . NAME16tn2... dill11Gll._ __._______ _.1 t'l G &OWNRADDRESS L. ._G e � -- _ .__ ----__: __ TE OS3_ygy YiAFAX- - TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL Q RESIDENTIAL — PRINT (T FART Y NEW:[ RENOVATION:© REPLACEMENT:9 PLANS SUBMITTED: YES D NOD APPLIANCES 7• FLOORS--' BSM 1 2 3 I 4 5 6 7 8 9 10 11 12 I 13 14 BOILER L_..._... •. ._ _ __._.__I1rI_. _.:. ..__, .. ..I_... ..1�M-�` - '-- BOOSTER 1MIM --_--- - �� -- -- L_...._ ._.._ I'®'Ll�l ® ®*1 ®®Ml®®®®®1M-Illi®®®®M CONVERSION BURNER COOK STOVE wwwwwanumminsmonoxwmnin DIRECT VENT HEATER MIMMIIIIIMMININNIIMINNIMIININEMIIIMMI FIREPLACE WIMiNWA ®®MNIE __lam®MI FRYOLATO- IM( ®MIM®i.limmi®®M®®®® FURNACE f l MMI -'I -1M GENERATOR . _. __ _ .. '®I I.... ..Imo'.... .I ..._....._i I._ L^i .. 7 L__1111 II MI MAKEUP AIR UNIT ® �OVEN ® - IWW ® ®_ WOWI® POOL HEATER L IIM — mu MIM ® ws�®IusI®I . I [�i®IM UNIT HEATER m ROOMUNVENTED iM®®®� INiIIMMlSMI®I®II--- . !MANUAL! WATER EATER®IMMMM®M� WMM OTHER _II®M'®® ®®®I®I® LM I i -T ____ • _---•-_. . ®®®I_....1®®®I�®® " - " - ummimi INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES n NO LI I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0 •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 0 S' 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 a ccurate to the best of my knowledge (- and that all plumbing work and Installations performed under the permit issued for this application will be in compllan with all Pertinent provision of the :Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -�, - `-" PLUMBER GASFITTER NAME I STEPHEN A.WINSLOW _ • 1 LICENSE#.12298.. SIGNATURE 6-- MP 0 MGF© JP 0 JGF 0 LPGI0 CORPORATION D#13281C`- _ (PARTNERSHIP Dr1 LLC o COMPANY NAMEI EF WINSLOW PLUMBING&HEATING .1-,I ADDRESS 8 REARDON CIRCLE _ -.-. CITY i SOUTH...• , •UTH. . •• _.. -,,..�_-._._-..--,I STATE MA 'ZIP 02664.- • ITEL 598-394-7778 _. . _ _- :, 4-8256 �� FAX 508-39 CELLI NIA . • , EMAIL accountspay�ble@efwinslow.com ,. ,. • The Commonwealth of Massachusetts ' Department of Industrial Accidents �:' ':;• 1 Congress Street, Suite 100 �+ Boston,MA 02114-2017 ' ww mass. ov/dia -sv0 wg Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):E.F. WINSLOW PLUMBING & HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): LEI I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction 2.fl I an,a sole proprietor or partnership and have no employees working for me in 8. I—I Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. [1]Demolition 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOF repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lic. #:1909A Expiration Date:01/01/2020 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine 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 of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and a pai s nd pen lties of perjury that the information provided above is true and correct. 1 � o Signature: ` °a ��k�_ Date: Phone#:508-394-7778 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#: