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HomeMy WebLinkAboutBLDG-17-000676 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -: ! Ira_G CITY ._..._. --_.._._ __ __�-ter,..._.._.__. MA DATE[ Jo a P RM # 840L'/7-0aGI (-7a, JOBSITE ADDRESS --3' 1 .14il✓40 -C-", —IOWNER'S NAME /0 i Y' GOWNER ADDRESS [_1'.l 4, . Lytr' 1 TELFn 7713y1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT © EDUCATIONAL RESIDENTIAL op CLEARLY NEW:EI RENOVATION:E. REPLACEMENT:D PLANS SUBMITTED: YESEI N01- ,q APPLIANCES 1 FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I '1. II- •'I _ i_� 11_ ti ii4 }1 .777_ _ _ -it BOOSTER I_ +I_ 11. I F1 1 i 11 h t 1 CONVERSION BURNER ll`_ Ire I 11 - .r.�l II ?I--- I. l tl '{ � I`..`�C� I(" 'NA COOK STOVE I _�._.: y - I. I I I --07-71E----11-77 O DIRECT VENT HEATER I 1 i 717711_7771-77_117.7.1177.117-77 to DRYER I 1 I( _ 11 ..� I (i ,1_�-;I i I— II` ! 41- .. ' N. FIREPLACE I I ((� yl. L . _ I _-_'1-- __II 1I I ,l '-'y i"-' i . I1 it .I " V FRYOLATOR i 1 f.._ (,,.- �^'.. I I . 17 I I I_ 'I 1 I �= I I _ 1 '1- 11 tf- 41 FURNACE ;I._...;N'r, , �� I `,I fT II tTThT GENERATOR I I___ . I_ . ,1. ,. ! . i I _ . II GRILLE ,I II- _ ... 1 IL.._ .;1----- ;1 - <I� I I;I d1— ir. _ INFRARED HEATER I_ I. (. V .`i r l --''i.--- +`l1 ' I =.1— I - 'I--;1-- -----'7-`'`-------; LABORATORY COCKS I Il.-- II- ;Ii- t1 'I _ '1 .. I. Ti- . 1_.. . ram.' MAKEUP AIR UNIT I I I.^ I . I �r I ;1 I' -.if- I7 I 1- � " hi 1 OVEN I 117711,_ I 11 ME1 y' H 11- I l_ •I Eat I(_ ! 'I ,POOL HEATER 1- 1� `I I__II.. IJ ._. i 11 III '1 "I (! 1! II I I ROOM/SPACE HEATER it . /L_. ` i it .!_ ;I----- 1----1 !1_ al I! ((-' /.I_ .jt ROOF TOP UNIT C_-IL JI . 11 ,81 ;I _ II. iI ;I ti it rI- tl tI__.. tl t TEST L. I -1 1 'I _'!.. ,'1 __ 11 . I -'1 -'1,T�ti.ET _._Il UNIT HEATER I.0 I.f.. l.iI d _.. T.. 7-i_ Y — __ UNVENTED ROOM HEATER 1-1 !I 1 -ir7 sI tiu_�'1._.. _;I '1_- '[ -l1 T tl -ili -, WATERHEATE 1 —II�II I 'I�. ! - „ -.1 -.- ;1 5i`�. ,I.. 1 ,I 1 OTHER _ _ I I I I.-- 'I- I L 'I -I .''!__. '1 . I.. `I `I i4- (. i -ll. i -_ - _--._.__.._ _-----!i------1 L.. I I I 1 :( 1 I _ I- T1._�., I. ;1� I— ! _ ; 1 - ! I r � l--- 1 - 1- I I . L_. __._ _....---- INSURANCE COVERAGE I have a current liability insurance policy:or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO D I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY El BOND 01 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 Ej 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 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 i ccompilan with all Pertinent provision ofthe Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , `,_ PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE# 12298 4 SIG TURE MP[ 1 MGF D JPj JGF{ LPG!D CORPORATION 1#,3281 C PARTNERSHIP El#C-;LLC D# COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE � CITY SOUTHYARMOUTH � — STATE MA--;ZIP 02664 �_jTEL 508-394-7778 FAX 508-394-8256 'I CELL N/A FI;EMAIL accountsmable@efwinslow.com Department of Industrial Acctaents i*=`--l' ® sce o Investi ations e solid;_wi .� f g i i_=:eY1�_v 600 Washington Street =3 ilr—a Boston,MA 02111�e,_:,,r www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information �^ ` , � Please Print Legibly Name(Business/Organization/Individual):E.'C-•W i, 5 Ova `l/��V�.,0 i✓+e� ta�✓�, Qs,--)I nit• Address: (te Carr c- • 0 City/State/Zip: Sos k`1 Icrv•-•Kajle, MF` Phone#: 'SOs-394-117c1 • Are you an employer?Check the appropriate box: Type of project(required): X, I am a employer with '70 4.0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors Remodeling listed on the attached sheet,t ;.❑I ship a sole proprietor no employeese pestner- These sub-contractors have 8. 0 Demolition working ng have no inayp workers'comp.insurance. 9. 0 Building addition forme any capacity. [No workers'comp.insurance 5.0 We area corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 1.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions c.152,§1(4),and we have no 12.0 Roof repairs mysranlf.[Noerworkers'.] comp. employees. workers' insurance required.]t [No13.0 Other comp.insurance required.] toy 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. :ontractorn that check this box must attached an additional sheet showing the name of the sub-contractors and theirworkers'comp.policy information. lm an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site ` formation. n � n 1 tstuance Company Name: I�fYYO . °Hoy#or Self-ins.Lie.#: M S oZ I PcExpiration Date: (—1' aO 11 sb Site Address:a3 r$Aan 1/41.1?0.-1{h 1 1 C 3' 1" ItIA-111 City/State/Zip: 1::),.),-4 ic,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 tie 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 ,::•nst the violator.Be advise tat a copy of this statement maybe forwarded to the Office of tvestigations. the DIA for insure? , overage ven a on. / do hereby certify u ins an penalties of p jury that the information provided above is true and correct. ignatufei—_._ ✓r.2 Date: I o.\31 1 a©1er hone#: 51)1•.�`('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#: