HomeMy WebLinkAboutBLDG-18-004542 .\ IVIASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK . \
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CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:IV PLANS SUBMITTED; YESO NOD Q
APPLIANCES 7- FLOORS-> 8SM 1 2 3 4 5 6 7 8 9 10 11 . 12 13 14
BOILER II.. ... ......... -'I . :I. _ l�7i .: 11_ I_ +:I- :l-_ '.I_.. :ir.__F-7-71..... -' \Q
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CONVERSION BURNER 1,71i �I[7.717.7.7 —" i.
COOK STOVE A1:—.-I. .7 _. ;--..-1-__._,IT------'FT I . _.I~_.- ,is
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FIREPLACE 1� -'.E _ (. -i----- �•--_ �_r-- -- -__ ,�T L. ;l_.v_-;1 ._ .�i� .w(_..w' - ._ _
FRYOLATOR 1v-y---.I. ..,__I .. _I: _ 1".---'.' 7- �I-- i - 71:7:7: _.•17_71 ;1-: !I._ :
GENERATOR ' 1 • :I' .__. 'I . 'L.:, -,i I - i i.'
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ROOF TOP UNIT II � l-__^I`+�.::.r.'I. .� `� I h� I 1 -- I_: . 'i' L� �....1
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UNVENTEDROOM HEATER �L-` ,`I. ;j ,(�, - '1.,.._a- I L.F,._�I__,_�'�. y I� - I _
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INSURANCE COVERAGE M
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES L1 NO ] 1
1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY D BOND D ""!
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the -1-
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER IJ AGENT 'G 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 d 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 compll ce with all Pertinent proviisionfofthe
. Massachusetts State Plumbing Code and Chapter 142 of the General Laws. !� /„�% �
J
PLUMBER GASFITTER NAME I.S T EPHEN A.WINSLOWA 122
1 LICENSE# 98___; /SIGNATURE�RE
MPD MGF El JP Ej JGF-7 LPGIEl CORPORATION 0#I 3281C E PARTNERSHIPD#L _.1LLCD#I
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ^1 ADDRESS[8 REARDON CIRCLE __.,......_ —1
CITY I SOUTH YARMOU T H_ M. � STATE! MA 1 ZIP 02664 TEL 508-394-7778 P
FAX 508 394 8256 :10ELL�A s -- - • - ` 1/-
EMAIL accountspayabfe@fwinstow.com _-_ ____ -T
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• 3
The Common
wealth of Massachusetts
Department of IndustrialAccidents
r ' 1 Congress Stye�' et Suite 100
!�! Boston,MA021142017
.._� www.massgov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FD;,ED WITH THE PERMITTING AUTHORITY.
Applicant Information
Please Print Legibly
Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO.,INC
Address:8 REARDON CIRCLE
YARMOUTH MA 02664.
City/State/Zip:SOUTHPhone#:508-394-7778
Are you an employer?Check the appropriate box: Business Type(required):
1. I am a employer with I employees(full and/ 5. 0 Retail
2.[] or part-time).* 6. Restaurant/Bar/Eating Establishment
I am a sole proprietor or partnership and have no
7. El Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8. Non-profit
3.® We are a corporation and its officers have exercised 9. ®Entertainment
their right of exemption per c.152,§1(4),and we have
no employees. 10.❑Manufacturing
[No workers'comp,insurance required]
❑ We are a non-profit organization,staffed by volunteers, 11.0Health Care
with no employees.[No workers'comp.insurance req.] 12.0 Other
y applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
ization should check box#1.
an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
nce Company Name:ARROW MUTUAL INSURANCE COMPANY
's Address;23 COMMONWEALTH AVE
e/Zip:
CHESTNUT HILL,MA 02467
r Self-ins.Lic.#1821 A
Expiration Date:01/01/201 3 1
,...,..�� a copy ofthe_workers'compensation policy declaration page(showingthe policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
fine 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
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi r the a' and enalties o perjury that the information provided above is true and correct.
/1/
Signature: f
� Date: l I f f
Phone#:508-394-7778
•
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.Licensing Board 5.Selectmen's Office
6.Other
Contact Person:
Phone#:
www.mass.gov/dia