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MASSACHUSETTS UNIFORM.APPLIGATION FORA PERMIT TO PERFORM GAS FITTING WORK
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CITY ; o c.. _.. .. .._ _...d1et hr o u .._ . .. , MA DATE,, _••..z -(/t PERMIT# /3l�J /S7-� of
JOBSITE ADDRESS; Z 4 T L l i j9t/E nl 1u cs I OWNER'S NAME P��;t, .,1�7 Lac p5, I
OWNER ADDRESS ' - --.-. _ - -_ TEL 77r ,;23,eQS2',,�FAX, .
TYPE OR OCCUPANCY TYPE COMMERCIAL!_.i....` EDUCATIONAL',,,,, RESIDENTIAL
PRINT
CLEARLY NEW::_, RENOVATION::..3 REPLACEMENT:>4 PLANS SUBMITTED: YES•_J NO Id
APPLIANCES-1 , FLOORS--) , BSM 1. 2 3 4 5_ „•6 7 8 9 10 11 12 13 14
BOILER , I .J I -II._. i t r 1; ,l: _i _'s L=___
BOOSTER is _..1 j ..1 .. w ,� I ;. '� I ..I:w_...rl•-.....-.3
CONVERSION BURNER N f 1- ....M i I._.--..Yi__, -I:....._T.-I 1 ... 1_ .VI• ..3_,__D I..__.- _ -.1
COOK STOVE _� � a J �. < I .� ..,w ....
DIRECT VENT HEATER I
DRYER i,.... ... -...-1,:. I . .I!5 I r._.-.. s.,...._I._.�..,., J ,J s
FIREPLACE 1E. J
` '_ I Ia 1
FRYOLATOR �..�.I� ...�.� I° ' - I' __--1�.._. �:' _. 1�,... -- - �I �...
FURNACE ; -1.; I .1 i I I I M_...Li ! 1
GENERATOR l E ~k I 1 . ._-..• I -1 . ' .
GRILLE ,.....,J.- #• ., m-_1` I: _I' ...._. 1_ —
INFRARED HEATER i Ll' I. :' I I : 1 . .. I . ..
LABORATORY COCKS 1 r i_ I J i i- I
MAKEUP AIR UNIT
OVEN f ' I I E! .� { I 1 .__ 1 • I....._ _.__ - t �;
i - fs F I .- 1: s_ t t ,—.I
POOL HEATER �.
ROOM I SPACE HEATER ! I; I; `'I ..._..I`�—I ---� I ' I I' '�" -"•-J
ROOF TOP UNIT 1.. F=,,.�. 71' �,
' 3 j ._._,_.l__-,s .. : .-t I._ .... _._...s
TEST :,,_.. ,, ` i' _ i:..__. �- 7 - -.-•I- _ 1 ----1 .-: --...__.. --. -.1:-. • ....
UNIT HEATER i I I• I' I I• I i r_ _...,! '1'_„ ..w.i i'
UNVENTED ROOM HEATER I'___. .;, I< I. 1'____._ _ I i _- . . _ _ _..._• . ..
WATER HEATER-- . »� _ I __ :__ _ 1. -
. _ I t _ J t ... 11. _ I I.._ _ I O�
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ILI NO .....j NZ
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY .....,-. 1 OTHER TYPE INDEMNITY ,.,,1 BOND f.,-_
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 ;..
. .,,I.
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 'ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��,444, i
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PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW_ LICENSE#'12298 r 44 1 l .1GNATURE
MP"! MGF. . JP ....II JGF:,_j LPG! _Li CORPORATION. #'3281C 1 PARTNERSHIP._?.#_ LLC 1#, ,_,_•
COMPANY NAME: E F WINSLOW PLUMBING&HEATING I ADDRESS'8 REARDON CIRCLE r_ ..,
CITY SOUTH YARMOUTH STATE i MA ,.ZIP i 02664 ITEL 508 394 7778
FAX'508 394 8256 1 CELL:N/A }EMAIL-accountspayable@efwinslow.com , ., . _
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. De par/%9aannt of!lng strIal Ammmons
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k A ®five ofInvestgatgons
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B ,r/on,MA02111 •
WWl0 rr� &gov/daez '
Workers'Compensation Insurance Affidavit: 1r zujklers/Contrzetors/EketrielartsfielmbersApp
liea,ct information
Please Pint Legibly' .• •-
Name(Business/Organization/Individual): E,c.W1�,sje� Q(0he` q.e.„\-A'
Address: . °�eteartia � D
•
City/State/Zip: „041eN , ,, , CAA- Phone#: S-3 t 1177
k?e you an employer?Check the appropriate box:
Type of project(required):
I am a employer with -70 4. El I am a general contractor and I 6. ®New construction
,employees(full and/or part-time).* have hired the sub-contractors
❑ 1 am a sole proprietor or partner- listed on the attached sheet.# 7• ®Remodeling
ship and have no employees These sub-contractors have 8. ®Demolition
workinng for me in any capacity, workers'comp.insurance, g• 11 Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.El Electrical repairs or additions
1.❑ I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions
myself.[No workers'comp. 0. 152,§1(4),and we have no 12,❑Roof repairs
insurance required]I employees.[No workers' 13.0 Other
comp.insurance required.]
'.ny 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.
•
im an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site
lrormdtion.
tsurance Company Name: ;,.J (`"1v Ott ,utu itCia. Ct, vvi
olicy#or Self-ins,Lie.#: \$ • Expiration Date: C--[ " aOl`
)b Site Address:,)3 Ausy CC Atil4 M City/State/Zip: O,),LIto 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
no 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
Cup to$250.00 a day against the violator. Be advised t at a copy of this statement maybe forwarded to the Office of
tvestigations the DIA for insurarpeloverage veri a on.
do hereby cal cane a sins an penalties o pe jury that the information provided above is true and correct.
i at4 • r Date: (oL l a t '
hone#: � I`]P 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
Contact Person: Phone#: