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HomeMy WebLinkAboutBLDG-19-002210 _— • lnn.nlAVI IVV6.1 tV V1c.l Vl\Itt At I LIVA11Vtc 1®I,-.-‘I lt.tl.t.>..w....•....... ................ ..-.. A.A... - ATV.:4' CITY \iUrIYIO11}k_____ _____._.�._.___. MA DATE� 1 I PERMIT# ,D�/Q� v JOBSITE ADDRESS / -_ OWNER'S NAME OWNER ADDRESS _P.o_1301A: 3 Souk W eJ4 mA TELSO83946581 FAC_ ___ ______I TYPE OR Ca 601 PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUC ONAL© RESIDENTIAL CLEARLY NEW:O RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ NOD APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER e-------, BOOSTER ICONVERSION BURNER 1, _ l . COOK STOVE - ��.� DIRECT VENT HEATER 111[1111 M DRYER ®® INN FIREPLACE -� -- FRYOLATOR � IIII FURNACE �_ _, _ _ GENERATORr - �I.L GRILLE II r INFRARED HEATER, __, i. - LABORATORY COCKS Ipi MAKEUP AIR UNIT d ' I a T t z OVEN POOL HEATER _ _ __ . - ROOM/SPACE HEATER 'i- 1111 ROOF TOP UNIT ,� ! TEST ` . - _ M I� rlll�_ UNIT HEATERMEOW UNVENTED ROOM HEATER 1111=1=' WATER HEATER _ �. — 1 r--- OTHER � V6y1 ' �>A� �_ I _ -- --- --- I. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES []NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY El BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the V) Massachusetts General Laws,and that my signature on this permit application waives this requirement. --F- CHECK ONE ONLY: OWNER ❑ AGENT 0 v-, SIGNATURE OF OWNER OR AGENT 'O I hereby certify that all of the details and information I have submitted or entered regarding this application are tru- :nd accurate to the best of my knowledge t. ) and that all plumbing work and installations performed under the permit issued for this application will be in comp—ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , / /� 1 �� / - , (/(.1.� a PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE •`7-1 -r- MPO MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION Dd.3281C I PARTNERSHIP❑# . _ _ LLC❑#I .__ I a COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH +STATE MA ZIP 02664 TEL'508-394-7778 d __I FAX 508-394-8256 CELL N/A _i EMAIL accountspayable@efwinslow.com 1,Q17 Gi J" �� A UGC LO/006006VYb IY6.666606 '/J 11166JJ666.060KJ0.66J Department of Industrial Accidents �'� l j 3/ ti 7='=�Vt>_�� Office of Investigatpons 1 _ii 1_a boy .f e t �n � Y ' �ii 6� 77d 600 Wttshingtort Street , • " V www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers pplicant Information Please Print Legibly \Tame(Business/Organization/Individual): E'Cr•W ty�l ow Ploo-.6 -1.cc \ ' Ce•)inC. kddress: (fit wl C ai 7,ity/State/Zip: So,s 'jcr c3,At,, µPr Phone#: 5O -394'-1 T7 Nre you an employer?Check the appropriate box: Type of project(required): I am a employer with '70 4. E I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet.I. ❑Remodeling 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.❑ 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 iy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • nneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 'ri an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site 9rmation. urance Company Name: v,.3 CAUkIO-)1 er. ,ruvui icy#or Self ins.Licc.(.��#: I$a 14 Expiration Date: I—1 — a0i� Site Address:3 (MrAcr/1 vi'e0-011 � 0,,e3 , it-I, City/State/Zip: DaLl(o7 :ach a copy of the workers'compensation policy declaration page('showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 ip to$250.00 a day against the violator. Be advised tsat a copy of this statement may be forwarded to the Office of estigations • the DIA for insurai-- ,overage veri j on. 7 hereby certify un e e aims a penalties 0 p•juiy that the information provided above is true and correct. nature ip- ' Date: a aot' one#: �ig:3 j1. 7?7g 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 5.Other Contact Person: • Phone#: