Loading...
HomeMy WebLinkAboutBLDG-18-006904 j O VIASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Jr,R=ci �;=_.11= CITY .�'S_ .„�.. . o._`'.. ........... t MA DATE_�_, ..� PERMIT# �/l6�$�� D JOBSITE ADDRESS`__/ i/ig P�j 9/v�;- C ii/l; I OWNER'S NAME 67,+/ c�L ay W L ST I G OWNER ADDRESS ...n.._',Ye) -pi- 14:.__... _....._._.. .... ._........_,,..,..,__..._...__._... I TEL: ,� 615 6_¢_3.I FAX; _....�w.w I TYPE OR OCCUPANCY TYPE COMMERCIAL;_I EDUCATIONAL ;_i RESIDENTIAL Ai PRINT CLEARLY NEW:'.,,,J. RENOVATION: ... REPLACEMENT:X PLANS SUBMITTED: YES......i NO;_„„I APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 s 7 8 9 10 11 12 13 14 BOILER l I._.._..t :__ I t' _._.i s.__--__.i L._..i,...�1 I`, BOOSTER .._. < _r.. i _ .s _.. . .I...... .._I ,.----I - ,.. ,'�__ 1..._ . I. _..�, . _w._ ... ___ w CONVERSION BURNER ,........_...; ._ I , a.,._J`L._Ili .... I.____If__..- ...I......�r_�...; v.....�..1..._.._..I .._._I._..._....._i_..._ .. 1 _ _: COOK STOVE ,i . i I _.I I ! I____J ._,_......I._. DIRECT VENT HEATER + - 1 ._ I DRYER .�...,.t , I .1.' 1......... 1 I j ~s t FIREPLACE € FRYOLATOR I .., I i.,-_,�_j' :' I _ .m..i;._-_,.-. FURNACE I :__.._J M.,..w.(_.._._I I .,.1._.. ._I s.�.___J I • I J GENERATOR ;. ..� ._._r_.! ,_...i ! �� ;:_�__I.._� I GRILLE __ . _...J I .J I ...I .... I _J J s INFRARED HEATER LABORATORY COCKS I .._:. . ! I I : —1 . — i. _ I I MAKEUP AIR UNIT i _._,_._._ . .1 I -i 4 OVEN ._ I: I .... POOL HEATER s i ROOMISPACEHEATER :....... +:•'-.._..__...la I ----- f i I• ___.._.I .. _I;. .. .i__ I1 i`�t.. ROOF TOP UNIT r ... ._I I I_..:. I I i...._J I — _.. .. Y TEST gs' DST Y �! / i I I , . _ _,_! I :I -_ I . I . I' _- I UNIT HEATER _ E I_._._ 1_..._.....__ ._... _.._-...j_____-"__. _... I J �- UNVENTED ROOM HEATER ______ I'.__ .:1:.. . ..•I , . ..I I i_ . . .I . -. . __;:__ ..n._..-i �J WATER HEATER _.. ...... .... - ; •I ... .-I.. . . ,�..... I • °__... I.. I I • I, I..�_. -- .I.___? OTHER ..._ . _ . . . ...I:.... I I.._ ......l'_.__1! ..............i_.__...I! I.. .......I- I .._.I I;.- _I I !' i E .. __.I . I.. . INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I +I NO ..,J I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i_I OTHER TYPE INDEMNITY 1 BOND k_ _i 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 comp nce 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 41 MGF _._I JP ......I JGF:,,,,.j LPG! CORPORATION•!I#:3281C 1 PARTNERSHIP.,. # LLC #. I COMPANY NAME E F WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE I CITY SOUTH YARMOUTH i STATE i MA I.ZIP 02664 TEL 508 394 7778 I FAX 508 394 8256 I CELL NIA I EMAIL accountapayable@efwinslow,com fi S� 4, 177�r�jp?9°C?rialtr& of i��2c°S?v'6ij�'At�:'gl`�lC'e'8ae-PE 2=. !,„t 'Office of Imes g€4io ; fr 600 Wag htijggOB SPeeeg t1 BosEoba,A 02111 <4.4, ?>? wWW 2 ' ogov/die • Workers' Co,1 dens to©in lime_t ra tce Affidavit: I:,11"aldgi /0©ntract®u's/ 1cctrracnans/Pl abere Applicant Inform tic,' Please a"lint Legibly Name(Business/Organization/Individual): e,c. iN i r.3 0 j `26,4to v i A_ 0.c a-4�1 city., 1 el c, J Address: $`' (4, Xevn Cs,rz_Q... • _ City/State/Zip: Soy kv'k av t`-1kPc Phone#: 50S- 1'17 ,1 . Are you an employer?Check the appropriate box: Type of project(required): with `70 4. El I am a general contractor and I '� I am a employer � have hired the sub-contractors6. ®New construction employees(full and/or part-time).* t 7, ❑Remodeling ❑ I am a sole proprietor or partner- listed on the attached sheet, ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. C]Building addition [No workers'comp.insurance 5. C] We are a corporation and its 10.0Electrical repairs or additions required.] officers have exercised their L❑ I ani a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. e. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.(]Other comp.insurance required.] my 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. y km an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site lrormdtion. isurance Company Name: Arty()•.,-} rk‘-Orli 0.-)\ S ,n ez, Co.�J"` k''1`) olicy#or Self-ins.Lic.#: \B i A • Expiration Date: —1 "' )01-7 ib Site Address:,a3 CC9rinrna7l a-1 -C`l One:��r'lA" IA1\\ City/State/Zip: ( ,) to 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 MG',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 aaainst the violator. Be advised that a copy of this statement may be forwarded to the Office of ''' _. ivestigations •:the DIA for insurr et overage yeti 'Ca on. ( f do hereby certify uno e e airs an%penalties o ,jury that the information provided above is true and correct. is atuec-._._ . , �`'.- t,a....4111111`- Date: (ot_ I 9.01 i54 --VVV\ hone#: ,5c •.h�1`(' 777g \., c. n 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 S. 6.Other N'--....:\.) . Contact Person: Phone#: ��