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Home My WebLink AboutBLDG-19-002273 �U/ MASSACHUSETTS UNIF.RGM APPLIOATIOI',9 FORA PERMIT TO PERFORM GAS FITTING WORK _ CITY : . O 1.+T/��%..,IZ,,'c ce 9 i/ I MA DATE /�' •.,/6•,if' j PERMIT#/ ir('� A/� _ JOBSITE ADDRESS:-1i.S --tie— ,T o,�z/C ,''(GQ 1 OWNER'S NAME' ... c .1 /- °^J OWNER ADDRESS ': fL �/L—` 6 TEL�Sdr 2, d�. .�., FAX, T TYPE OR OCCUPANCY TYPE COMMERCIAL°.^•I EDUCATIONAL'„�t RESIDENTIAL:.A PRINT CLEARLY NEW:'r�I. RENOVATION:,,.._1 REPLACEMENT: _.3 PLANS SUBMITTED: YES._,1 NOi.L1 APPLIANCES 1 FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ! I. — — _ BOOSTER `_ },: _ •i , _M1 .._ is t .�.:F- , t li;...1._ CONVERSION BURNER iN.,._,_.J._ ---i.�.., _i ii ,-1. 3—_ .I..... -- 3 w.1_—_— I...._....`.:__.. -;:iI I COOK STOVE L,_.._.a.l.___: i' 1 i' I ,! I I I'_, I.. __I'___,j DIRECT VENT HEATER i i i'. ! I R 3 • ' -I- j I° _-1'— _ i:: t:, r: J t. .. DRYER �• _ I,m.�..�.i . I.n � .—.1,-- FIREPLACE , (: : ' _ r � FRYOLATOR i_ t ;'` is i' ; l . ' i, . _ ,� � FURNACE :_uJ, -- !1�--is : I _.. —,.,—,1„,..„,„' —— ... ' GENERATOR ! =s is .� ..:..-€ _.._-�._ ..1 �� 1 ._ .. . _.NI :. _ f. :......... GRILLE w—...:..IL_.—_.. . _ -._... 4.. ,.-mil INFRARED HEATER _ LABORATORY COCKS ,„...,„,a,.. - .. .. i _,_ -.. .._.. I _ ._ . I MAKEUP AIR UNIT ,_ I,_„ i f I i i' j I -,.-.� OVEN ! . 1 .1' i i I i - J I -- POOL HEATER '! ii 1 ''R ! i ` t I I . . ROOM!SPACE HEATER 3• f _i —= , , '. 3 I t t_____r I i__.___I ROOF TOP UNIT it r I• : .-_.Ii . • I i:_. _,_ �-1 I ; TEST CJ1e7,'z Loc,C'cf—b . .1_..}`. =1; A.�. . I. .._I ... ..7:. ;,... M i_ i . .. .i;L i. i).. ` . . UNIT HEATER ! _._.�; f: ( I � .._._.._..� i UNVENTED ROOM HEATER i, 1' i_ , .. I.:... ! I __ _ _. i g7 WATER HEATER .............. ._ •'——— , f1 ! F I J!_ 3 i — OTHER._._.. .__ ._ .._._ ..._ ._ . . ..i: i ' _Ir--'I —— Ii i is I___ J .z` I E u. a SE _i - _ f V 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 ,.-,:i OTHER TYPE INDEMNITY BOND L., 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 „1. AGENT E.....,I' SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tr - -nd 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 corn r ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / / � - • . ...... . _...g - ,...... -.4 .,,,,......, PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW 1 LICENSE#:12298 F ' SIG ATURE . MP. .1 MGF.,,._I JP _-i JGF:,.j LPGI :1 CORPORATION• #:3281C i PARTNERSHIP., # 1 LLC _. #. COMPANY NAME E F WINSLOW PLUMBING&HEATING j ADDRESS•8 REARDON CIRCLE CITY SOUTH YARMOUTH j STATE ill MA I ZIP i 02664 [TEL'508 394 7778 FAX'508 394 8256 I CELL:N/A IEMAIL.accountspayable@efwinslow.com 1 ,- Dep sr'It e g ofbedusgrl7gAccemc$ gel R,1. Office of]1ive igtsgion's i� z` 600 Pl Iii iggola&peel Bagok 11- 02111 WVlYwoUl1(. sagoy///j Worker'Compellnsati©ra Erfamntratnce Affidavit:llf allideas/Comtkrcactors/ERertriciarns/Phi lbe:r� it Ilea rtlI®rc�>ga��nOra Ii s, )mai>rn'tILe 1311 .• jme(Business/Organization/Individual): E,e.tivflAsiow Q(V 6 i1 L 0 z V:1' . cle kit. d d.dress: 7s �.� � rr .� 1 ily/Stale/Zip: joys-� Yt'�-vcr- i,dA- Phone#: S-3c-N-117 c' i 'e you an employer?Check the appropriate box: ape of project(required): \,., (� I am a employer with `70 4. mot': ❑ I am a general contractor and I 6. ®New construction employees(full and/or part-time):r have hired the sub-contractors ] I am a sole proprietor or partner- listed on the attached sheet.: 7. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance, g, ❑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 11,0 Plumbing repairs or additions • myself.[No workers'comp. e. 152,§1(4),and we have no 12,❑Roof repairs insurance required.]t employees.[No workers' 13.(]Other comp.insurance required.] my applicant t-.,t checks box#1 must also fill out the section below showing their workers'compensation policy information. lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. ontractors that checkthis box must attached an additional sheet showing the name of the sub-contractors:apd their workers'comp.policy information. Tara an employer that is providing workers'compensation insurance,for my employees. Below Is the policy and job site 1 rof mfdton. , suranceCompanyName: AY'0•,,.s C`k.1 vct)i ( f ,.t C ",n- • )licy#or Self-ins.Lie,#: \ 'a) A Expiration Date: f---1 '• a(`3l`7 )b Site Address:,)3 rtnrnail v a-O km.') Ctne3414, 1 City/State/Zip: O,)4 to 7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). iilure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a no 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 'up to$250,00 a day a ainst the violator. Be advised at a copy of this statement maybe forwarded to the Office of westigations(the DIA for insuranet overage veld Gaon. / do hereby certijj)an,e• :e sins ant penalties o cp jury that the information provided above is trace and correct.ir i&nat&:: - r Date: (ot_)3 l i aoltri Iloilo if: .S1)S•? H r 7 7 7 X 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#: - .!