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Home My WebLink AboutBLDG-19-001711 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =5101— i Ec CITY d# a MA DATE 9 PERMIT# / 7// JOBSITE ADDRESS XW ec l_ abz -/ i!'�;,.., OWNER'S NAME•4900 - VdrA co...._. OWNERADDPESS ' M4,0TE {r _ FAX TYPE ORi9 rysg di 70 PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW:: _ RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES } NO' APPLIANCES Z FLOOR: BSM 1 2 3 4 5 6 7 8 9 13 11 12 13 14 BOILER BOOSTER . . . - CONVERSION BURNER COOK STOVE r`r c> _ DIRECT VENT HEATER 1 DRYER FIREPLACE - _ -- - - - -- FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN _ - ----- - POOL HEATER ROOM/SPACE HEATER _ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER. .. . . OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES � NO «, I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY r' 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 AGENT .�, SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are t e 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 co r liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 1229: SIGNATURE MP ' MGF JP JGF LPG! CORPORATION # 3281C PARTNERSHIP # L LC # COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508 394 7778 FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com vl— • A I&U. ♦-.vrrcircvrcrra.arcers vJ lrl WJJK\.I{41Jt.ipyl , *i Department of Industrial Accidents 1 ,� 1 Ml= Office of Investigations 0 = t_e W.. .1 600 Washington Street Boston,MA 02111 • us www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): -.1-•aii'sd\J k:,.�v ,•-i >hlJ ieici L. t-i.tc h vv., c'., )el( , 'J j ) Address: ' iSPcr. v ~'itr _ City/State/Zip: SC.,. v't ' c mac;,,' t r Phone#: '5 5- ti-T1'? Are you an employer?Check the appropriate box: Type of project(required): _^ `am a employer with l0 4. ❑ 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 roprietor or partner- listed onthe attached sheet.t 7. ❑Remodeling - ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity., workers' comp.insurance. 9. 0 Building addition [No workers'comp. insurance 5. ❑ We area 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.❑ 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' I3.0 Other comp.insurance required.] thy applicant that checks box#1 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 an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. tsurance Company Name: f4nC: rC L hic,,i •yn f L;VZ4 'c"co .,`-vi olicy#or Self-ins. Lic.#: A '3 a 1 A - Expiration Date: c—/ — ,-Oi9 )b Site Address:. ) G-,,,,,,cv k,,,t,c 4irk, ;l{-,, J Cine irij4' 1 11 City/State/Zip: 0,314Co7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure 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 against the violator. Be advised that a copy of this statement may be forwarded to the Office of tvestigations the DIA for insur overage verif anion. do hereby certify un e mains an penalties o pe jury that the information provided above is true and correct. ignature-_____ _------i' �- 4 ". ! C' Date: l D. hone#: cis: 7;54 - ":I ?T Official use only. Do'not write in this area,to Ire 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#: