HomeMy WebLinkAboutBLDG-17-003538 #G Ci.... . V,"7 C (6 11-s 64swe n
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Z `:ry_. —. CITY 'lit-row 6�_..0 H" _ MA DATE it./- ('9 /7 :PERMIT#a-De/7-X D'J r
i`k JOBSITE ADDRESS /4'I �«/ i/A /Ji2 t/ OWNER'S NAME[ # n J4Q /y 'im
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OWNER ADDRESS S. G ' 1 TEL 50S 77&Lily 971FAX 11
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL[] RESIDENTIAL
N PRINT
CLEARLY NEW:E1 RENOVATION:Lj REPLACEMENT: PLANS SUBMITTED: YES j NO
APPLIANCES-1. FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I = -
BOOSTER ..r. —
'O CONVERSION BURNER 1— i t_ l 1 ! i I --:]1-- +,I -.il_.- I I.. .!I 411-7- 1i C _ H. ..:
'O COOK STOVE 1_ 'I- I i ! l ! ;1 i i _l - Ai. +11
DIRECT VENT HEATER I C I 1 I. '�i -f I ..._1- ,j -' --� I ! (I f EIS
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41
DRYER I `I. I�.._ !!.... I i, .,L. I! '.. ... 'I I 'L._... ,L. 11 i
FIREPLACE 1 - -.
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FRYOLATOR I . I _....5--- -t--..;!,.-.._-.1�_. ;I- _: 1--_---.-.1 �--;
FURNACE I _,..-__,lam C'7- _SI
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I.. . I JL-. _ fl - H
GENERATOR L. .....• ,I..._ '1 - ;I !. 'I_...._ i ....!1 -- '-
GRILLE
INFRARED HEATER 1_--. i--.-ll_- _I
.1_7-
. - --71_. . 'I_ ..
LABORATORY COCKS
MAKEUP AIR UNIT I_ I --- .I;. _-1--. ;F_.._ ,_ il._ . ! . r
,I f l.-
_ ... --- �`— -- - l--- --- _-- _
'
OVEN �`_ ! I _? it I _ _ I i I l_ ,C
POOL HEATER 1 -_-,r .' _ l 'I f f,. I I!- .,
ROOM I SPACE HEATER i I__ _i_ _ I_ I . .il_ I, , I_,. ( _ _
1I _ !i
ROOF TOP UNIT _I I. ` -_ � ! 1- Ci ,:L- I.-_. t1 !
TEST i - I- --- Il 11 - �= � i(r--C1_
UNIT HEATER
UNVENTED ROOM HEATER ( T -
WATER HEf� ER L .. I I ; 1 -- 1 1. i i :
OTHER II ._I 1_ Cr-
1 •I I ,L_ it _. _4 _ ) . 1 'I ,l
INSURANCE COVERAGE
I have a current liability insurance policy oor its substantial equivalent which meets the requirements of MGL,Ch.142 YES El NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L OTHER TYPE INDEMNITY BOND
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 0 AGENT D
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 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 comp! nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ZI
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW 1 LICENSE#L122 98 t SIGNATURE
MP El MGF El JP D JGFD LPG!Li CORPORATION F# 3281 C �PARTNERSHIP D#I LLC 0# '1
COMPANY HEATING L F W NAME: EINSOW PLUMBING&HEAT
� 7ADDRESS 8 REARDON CIRCLE ,l
CITY SOUTH YARMOUTH — STATE MA ;ZIP 02664 1TEL5083947778 ''
FAX 508 394 8256 CELL NIA��$_ ;_EMAIL accountspayab!e a efwinslow,com _ ___ __ _
Department of Industrial Alcctaents
1'='°'E7
=litlt=; Office of Investigations
_'tsM►'=z 600 Washington Street
3'3�_'� Boston,MA 02111 •
,,,,. www.mass.gov/dia _
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers mil'
Applicant Information ` Please Print Legibly •
Name(Business/Organization/Individual):E,C•VI,A5VOvid Q(klin a.kincct L q.e.o�t�✓�, cO.) s-tl.
Address: �P � Carat?. Q
City/State/Zip: Sos k \ wwc>„-1,-t NPc Phone#: ‘50a-39`I-17?Sl
Are you an employer?Check the appropriate box: Type of project(required): �___
,,1I am a employer with -70 4. 0 I am a general contractor and I 6. 0 New construction
employees(full and/or part-time).* have hired the sub-contractors Q\ 1
!.❑I am
a sole eproprietornom or oyeertner-
listed on the attached sheet.t 7. 0 Remodeling 1v
ship and have employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its
officers have exercised their 10.❑Electrical repairs or additions
required.]t.❑I am a homeowner doing all work 11.❑Plumbing reairs or additions right of exemption per MGL P . Q?
myself.[No workers'camp. c.152,§1(4),and we have no 12.0 Roof repairs
t employees.[No workers'
insurance required.] 13.0 Other
comp.insurance required.]
1ny applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:ontractors that check this box must attached en additional sheet showing the name of the subcontractors and their workers'comp.policy information.
jm an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site 1
(formation.
tks11-va� N./V/1G Cev�akrri
tsurance Company Name: (r1Y YD.S
olicy#or Self-ins.Lic.#: \S a 1 A' • Expiration Date: t--j apt-)
tb SiteAddress:�3 COn.r anw-eo--[1"h Adsey C'Ne31 ` I„ City/State/Zip: O -4 to 7
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
ne 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
f up to$250.00 a da a ainst the violator.Be advised at a copy of this statement may be forwarded to the Office of
•
tvestigations the DIA for instuapetrroverage veri to on. /
do hereby certify an rns an Ilpenalties o pe jury that the information provided above is true and correct.
(( Date: i--I 3I 1 ao46"
ignatu3:
hone#: 5.1791•35`i'777g
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
Phone#:
Contact Person: