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Home My WebLink AboutBLDG-19-006284 (2) MASSACHUSETTs I_UNIFORM APPL!CATKIN FOR A PERMIT Tn PERFORM GAS FITTING WORK ,ram-� r _: _ (/ 1 r PERMIT# i*.db-/9-0� �2 1 SY .-- CITY yeirlizaTITR_ l . Ci_ MA DATES a T f_� JOBSITE ADDRESS ...136. V_n.Ian...5t._...__. ._ ___ OWNERS NAME ('Ql1 f 1-_ S. _. GOWNER ADDRESS SamE___ .__ __________________ TELLyO N.q'.!7s5 Ax,-- -- ._ . _.. .1 TYPE OR OCCUPANCY TYPE COMMERCIALD EDUCATIONAL D RESIDENTIAL111— PRINT CLEARLY NEW:D RENOVATION:D REPLACEMENT:L PLANS SUBMITTED: YESD NOD APPLIANCES 1. FLOORS-) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - - - _ I ,r BOOSTER IIIIIIIIIIUIIIEIIIIIIIMIIIIIIIIIIIUIIIIIIIIIIIIIIIIIIIIIIJIMIIIIIIIIIIIIIII CONVERSION BURNER T-i M[ MI ( ] ;N]i l—M_ DIRECTIIIIIIIIIIIIIIIIII OOKSTOVE VENT HEATER IIE �� DRYER 1 JI -{ a IM LII AI -- II 1 FIREPLACE { ,I �-1. _ 1 _--' - FRYOLATOR I AMU L_.,___I - _ �_ -_- - _MIN --- FURNACE L_IMII[J�� I�1MIIML _Imo GENERATOR MIONIMINIMINUMENIMUlt _IIIIIIIIIIIIIIIMIUMMIN GRILLE i_L_. ILI L -11_- _iwilINFRAREDHEATER I 1. __ I {[ .__1L -_I1.I I L ._ IL _ — 1miI .._.-I LABORATORY COCKS Mil L--'�� — I 1 1 I_ _r MAKEUP AIR UNIT L.___Li __ il— -- T1L___ 1 II J . 1 _t._J -_ OVEN rill 1___ J I _I --.: -___ I I L_ _J-- IL--- POOL HEATER IWIIM I I I I=:-- _ 1'_._. II —J ROOM/SPACE HEATER _._ -_- _ _. __- �,- - I _ � - ---- -II I _ I--1 ROOF TOP UNIT Ear— _____TEST -- ® - ®. _. 1--wwww, UNIT HEATER ®�� 1®�I I [ MOMEM_ EIMIWOMILINII UNVENTED ROOM HEATER MilltM_NIMIIIIIPIIIIIIIIUIIIIIIIMIIIIIMIIMIIIIIIIIIIIMIIIIIIIIIIIKIIMIIIIMIFWATER ____ OTHER HEATER Mi �� — �i�_- ILE-..._I �I J �I . _ IL_ I L_ L 1 — I7-1 ®� _ I—— f II- �'- I...... . L_—_L_ IL._ __ L_ IL_.._.--- l[ L—y.. C_M 1== CNO INSURANCE COVERAGE I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES D NO D (7--- I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY F0 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER D 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 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 compli ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. c PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW _ LICENSE# 12298- SIGN TURE MP LI MGF 0 JP D JGF 0 LPGI Q CORPORATION D# 3281C PARTNERSHIPD# . LLC D# 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 50 le PC) c ?1.:\ -6 06'6. 6-+i/IQ6606V66 VP".6666y6 V./ 1r366.y.y66Ybb66ULb6V t =ft Department of Industrial Accidents jOffice of Investigations :: _ 600 Washington Street .„1;,,,..— � MA 02111 Boston, fs'_" ._ - - - — - - www.mass.gov/dia— - Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information { Please Print Legibly Name(Business/Organization/Individual): E,c---•i. i ` Address: �k,e cv) E rd iZ 0 • ) j�C City/State/Zip: 5.0.,-cti\ Ycn,, ,cj,k, Ntry- Phone#: '506- 39`1-1 T?S Are you an employer?Check the appropriate box: am a employer with —70 4. _ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction ;.E' 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 working for me in any capacity. _ workers' comp.insurance. [No workers' comp.insurance 5. _ We are a corporation and its 9 ❑Building addition 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 12.0 Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.0 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 formation. tsurance Company Name: � (}\- y CA 1,OA ` rk. olicy#or Self-ins.Lic.#: I S Expiration Date: (~t — 6.-c7o )b Site Address:D3 Crv,N,e91 te e.l Ad,eJ0,-,e3,, . I41 I1 City/State/Zip: 0��L}CO 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 [up to$250.00 a da against the violator. Be advised t at a copy of this statement may be forwarded to the Office of tvestigations the DIA.for insura overage verif a ton. do hereby certify un a ze ains an penalties o pe jury that the information provided above is true and correct. t..-- Date:Date: (DI 3 i i a01q. hone#: .s—N, ,-;ciui - 7 77X 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#: