HomeMy WebLinkAboutBLDG-19-004161 I I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
n _ CITY 0 MA DATE Oi/(5/.,( 19 PERMIT#,i /9'G°'i/4/
JOBSI'IEADDRESS ) _... ._ it _-®�.; _- -_'._. OWNER'S NAME pUrc? Lt)skft
GOWNER ADDRESS I S.ar._,c1-e_I\ A _ - TEl gI-J1-} 1'SIF
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIALS II ' ONAL ID RESIDENTIAL[
CLEARLY NEW:O RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES El NO I
APPLIANCES 1 FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
V._ _BOILER _ IL i II 11 1 1.1 4 11 - j II , _ .. _ ____ 1
BOOSTER __ __ __ II 1 I I I ._ II
CONVERSION BURNER L.-.-_.j. _.- _L . 11 -__ II_ 1171; II----II II. - . I II II_. i(_
U COOK STOVE I1 _ I il -._ _I-- _ II - -1 I 1 1__ 11 I . I II I
--. DIRECT VENT HEATER I IF-I II _ .:II I' I II- I. _ I1 II (I II- -
(3-- DRYER - -- - 11- ____ I I 1. I HL
1 I If-1 ICI_ I
d-- FIREPLACE 1` j I lI _ �;__ I _. ._ I I i----1 _�- l
FRYOLATOR 1_..- .._ I ._ I.. ...II_ _.___II._ __I, __ __ _II__ . II--___ 1 1 I II
FURNACE 1 I II 11 I 1 II I _i ___ I I' _ I 1
GENERATOR I._. it_..._ 'I -I_ .. I
GRILLE L___:_1 IC---II-_.. I ' .............j.... ...1
JI - I 7-1 I __
I_, INFRARED HEATER . ]r _ 11-.l1_ ____II_... 1.-1 _IL,_ . I__ 1______I __ II ,I [_�___
E LABORATORY COCKS I I It 1 _ II I 1._ ._— I I . 1 __ -1 .1_
--) MAKEUP AIR UNIT ®MN I 1111 1
OVEN i L jiMil. . IL II- _I I I I
POOL HEATER I _ 1 I _ II - 11 1_ I IF .I
ROOM/SPACE HEATER I L_
ROOF TOP UNIT I__I _ F 11 _ _ I�_.-=� _ I — I �_I
TEST �_- _. I I I
UNIT HEATER __II1 -
UNVENTED ROOM HEATER I I I ' . i
WATER HEATER IIIIIMMIIIIIIIIIIINIMIIIIIIIIIIIIIIIIIIMMIn.
OTHER --- 1 __. 1 - I - 1111111111111111=1111111111__ .__1lW
_I m_ _I. __ i___I__-_ I __I IL___I_. _.1:_- .I_ _ _____ _1__ _1_.____I
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cc INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES []NO Q
e I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND Q
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.
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CHECK ONE ONLY: OWNER Li AGENT 0
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 compl' e with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME PSTEPHEN A.WINSLOW LICENSE# 12298 ' SIGN URE"4
MP 0 MGF0 JP LI JGF Q LPG!Q CORPORATION 0# 3281C PARTNERSHIP Q# LC Q#
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA . ZIP 02664 _ITEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com
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vyl_� 8'sc. C..i/ll6ll6Vl61YL11.6616 VJ 11866JJ66\.1665J(.66J
O Department of Industrial Accidents
Office of Investigations
E. —ll'— 600 Washington Street
' ' - Boston,MA 02111
„ t ' v
o www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): E,C"•\N i �l o , ),N. '
Address: (1 p v )
l�PN_CVI Citue-
City/State/Zip: Sc,,s-c'v\ ycv'i,Ic„1-�, NA- Phone#: 1- 3—1-1 T7 I I V `'
- s, c)
Are you an employer?Check the appropriate box: Type of project(required):
Iam a employer with —7O 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 proprietor or partner- listed on the attached sheet._ 7• ❑Remodeling ��
ship and have no employees These sub-contractors have 8. ❑Demolition
NOworking 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
1.❑ 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 12.0 Roof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13.[ Other
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
tformation. k
isurance Company Name: {fl'ow ;`Av 1.1ail 't ns,c,NrEA el C r ,`may
olicy#or Self-ins.Lic.#: 1 'al it + Expiration Date: (—[ — D-04
)1)Site Address:D3 G.vnrvG�'� )v. e t Ad CG,e364, I'h(� City/State/Zip: 0,) (-0 7
.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 t at a copy of this statement maybe forwarded to the Office of
westigations the DIA'for insura •- 'overage veri on.
do hereby certify un a ze ains an penalties o pe jury that the information provided above is true and correct.
?e: �t^-i atu
Date: ( �i ll
hone#: .c . ' `1'11 7.7.Tg
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#: