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Home My WebLink AboutBLDG-16-006623 iL\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK , 8 Ii.-----'73 ir---L-=t v '--F VAIL-7•5' CITY Vci.,4,2 wilt-) ...7,... , MA DATE 6,6...,• /(,,, IT PERMIT# ..., JOBSITE ADDRESS, 0 e )211/14 graq 0 OWNER'S NAME -- ,, G ,. OWNER ADDRESS W 4,4)0201,771-1- 2TELle 74,T7 9440 FAX ..._,N ... ,,, TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL J EDUCATIONAL ' RESIDENTIAL .1.4" _... CLEARLY NEW: _I RENOVATION: .....i REPLACEMENT: .....1 PLANS SUBMITTED: YES NOt, 7 APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 -..' BOILER I _ i :__ _1 BOOSTER i_I J. i I_ CONVERSION BURNER = _..., 17_L . _ I R COOK STOVE . . __ 2. ,._.3 I I I _I DIRECT VENT HEATER f I _ _I __I __. _ ' ,3 . i „ _ ___.i____.1___ _ J Vi? DRYER i I. 1 __J I _ 1______ _, _ I 3__ 1 FIREPLACE LI I , __...i , I i I i FRYOLATOR ',,, I I J_ _ I 1 I ___I i I 1 FURNACE t _j ! I I_ _ __,1 GENERATOR GRILLE __ _ I I I INFRARED HEATER ' ''. f i I __I ' ' __I LABORATORY COCKS _._.1 -..! MAKEUP AIR UNIT I .. _ ._ OVEN , ...1 _...i I I I I _. POOL HEATER ...„1 i _ __!. _I .J.____I __I_ ROOM/SPACE HEATER ......1. J _ __1___ _ , i _., I 1 , _I ROOF TOP UNIT _....J , i ,_..... _ J ..,, I , ! 1__., TEST . --.1 1 I — , ____I_ ' ..1 _i 1 UNIT HEATER „.. _ _ __I _____ ___ UNVENTED ROOM HEATER 1,. ..„ WATER H TER i _ , _ OTHER -tei,5r-ifr i-0)‘... . , - --- -- , f -- INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I i NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY .'1 OTHER TYPE INDEMNITY •,,.J BOND 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 _...2, AGENT .......1 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 complia with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A WINSLOW LICENSE# 12298 ; SIGNATURE MP .4.1XMGF ,..J JP _...) JGF j LPG! CORPORATION i # 3281C ; PARTNERSHIP _....,# 1 LLC .....4 Jr1 COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 - — - / _ -.._____... ,........ FAX 508-394-8256 CELL EFWINSLO ;EMAIL ACCOUNTSPAYABLEGW.COM .... . ..,_i I • -_., ..,...,, ...._ ...... ___ _ : . 1_1111.:' 7TTIvILINT I : JUN 06 2016 , g Z.. __ _ _, 1-- , cp The Commonwealth of Massachusetts w— DepartnantsfIndustrial Accidents _.-.1=- Office of Investigations _ fill' 1 Congress Street,Suite 100 4F a Boston,MA 02114-2017 .,,.�.0'� www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E. F.WINSLOW PLUMBING&HEATING CO.,INC. Address:8 REARDON CRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): I.❑� I am a employer with 70 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.: required.] 5.0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c.152,§I(4),and we have no 13.❑Other employees.[No workers' comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their wotkers'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. :Contractors 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.#:1794 A Expiration Date:01/01/2016 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 Section 25A of MGL c.152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations oft IA or insurance co erage yeti cation. I do hereby certifyunaymiins and enalties 'aptly that the information provided above true 0 1 and correct ,— 64, Date: Si ature: Phone#: 508-394-777 Official use only. Do not write in this area,to be completed by city or town official. l City or Town: Permit/License# \ Issuing Authority(circleone): \ I.Board of Health 2.Building Department 3.City/Town own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other --Phone#: Contact Person: