HomeMy WebLinkAboutBLDG-18-002421 ASSACHUS! S UN[WORM AI PLrA IION FOR A piRpbgrr.0.PERFORM GAS °9sTMO WORK
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JOBSITE ADDRESS !-4....,.(�J_(�C 1 19 Bra. OWNER'S NAME ___,t 1,5 „^,.,,, 1.f—�°••* ---•--
GOWNER ADDRESS -- __ I TE i - _ .—
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL'-,) RESIDENTIAL/ r -
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�����`�� NEW:Yi RENOVATION:Ls.; REPLACEMENT:_-.`- PLANS SUBMITTED:YES NO i?, (Q
APPLIANCES-1 FLOORS-4 BSM 1 "2 3 4 5 6 . 7 8 9 10. 11 12 [ 13 114
BOILER •�_._.1 ',._._,....--- `... `_..,: _.--... ----'.P~~ ---- --
BOOSTER • - Y _.�'_.- ~.. . _ . ;� t E
CONVERSION BURNER 1,-;_„-_I -.• 37_.^. .. I •._, . .. I _. ! — I_T. --..._•. _
COOK STOVE I,� • `. i ' —..,d
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DIRECT VENT HEATER :.___ ___, �._.. ..,__,!- , ..�..m '• .. Z . .. 'a. m,• _.._;: i ..—......1
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DRYER 1, _ • ._ b __I..,�..,.; _ ____:J _ . ,_.... a�Ti___ __ .
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FIREPLACE f - `_ __ f.. ._ > m a, [ 'PM
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FRYOLATOR -= .:'' I�.._..,•... ...._t�..!- -
FURNACE -.,....�i_. _,, • _ I,._ :..._-I, -.,: �......,� .� .i�.. -..�..
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GENERATOR • :.I� ' ...,�.` ..i R . _F ._ ..._- ,_.� '--”'--”,..1 ...1:1.- -. ---
GRILLE `:_._.-.-i.._.. ___ m...- . .._. 1 .. ,..___.,l
INFRARED HEATER .... .. . _ ;__I_I,._,- -1 - • —1-1--
LABORATORY COCKS`. I_.-•-;._ _-• __, : - , -- -...: M .._, _I.—.• ..-ANEW
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MAKEUPAIRUNIT �__ ._._� _. ... .._.. l .... _1 . �, 1 _ ...,
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POOL HEATER -. : —. .,-�...! _,-- _ i-- - -}�e._.
ROOM 1 SPACE HEATER - '.�...,,i :. __-'• • ___i — ' :,1
ROOF TOP UNIT •
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-UNIT BEATER _- 1 . . . .. -- _`_`1.. o" .."..`:�.`�Y,.i�'.
UNVENTED ROOM HEATER ._.. ._ - -� • _; _
WATER HEATER.._•----- -_-._...___..,:�I r T; • i �-; _ _k � , • ® -,
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INSURANCE COVERAGE ..
yI have a current liability insurance policy or Its'substantial equivalent which meets the requirements of MGL.Ch.142 YES L r i NO L .
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW , .
LIABILITY INSURANCE POLICY`• : OTHER TYPE INDEMNITY �,..J BOND Li . DA
OWNER'S INSURANCE WAIVER:lam 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 ,...1 AGENT tTf
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are tru 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 comp ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. D
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—' -� SIGNATURE PLUMBER GASFITTER NAME STEPHEN A.WINSLOW,�,�_ _ _.'LICENSE# 12T98,„; __ _
MP'+ MGF...;, JP , JGF:,:•`. LPGI• CORPORATION rI# 3289C 'PARTNERSHIP.2#___ _ a -
COMPANY NAME: EF WINSLOW PLUMBING&HEATING i ADDRESS.-8.
REARDON CIRCLE a- PIt-
CITY SOUTH YARMOUTH _ u � STATE' MA ;ZIP 02664 ,F;TEL 508 39 4 77T6 __.��-i
FAX'608-394-8256 I CELL N/A o EMAIL accountspa able@efwinsiow.com �. _ . - - _,_ -•--• Le
The Commonwealth of Massachusetts
1 Departr entofIndustrialAccidents
f�ti 1 Congress Street,Suite 100
i
Boston,MA 02114 2017
Nimir 'r�0 wPvw rnass.goy/dla
Workers'Compensation Laurance Affidavit:General lausinesses. \
TO BE FILED V'4'ITHTII PER1VHITINO AUTHORITY.
p lieant Information
Please Print Leal c
Business/Organization Name:E.F.WINSLOW PLUMBING&HEATING CO.,INC N.
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH,MA 02664. Phone#:508 394 7778
1\
Axe you an employer?Check the appropriate box: Business Type(required):
1.[f I am a employer with 1 0 employees(full and/ 5. 0 Retail
_ or part-time).*
2.= I am a sole proprietor or partnership and have no 6. Restauranf/Bar/BatingEstablishment
❑Office and/or Sales(incl.real estate,auto,etc,)
employees working for me in any capacity.
• [to workers'comp.insurance required] 8. ❑Non-profit-
3.0 We are a corporation and its officers have exercised 9. LI Entertainment
their right of exemption per c.152,§1(4),and we have 10.[]Manufacturing •
no employees.No workers'comp.insurance required]**
4.❑ We are a non-profit organization,staffed by volunteers, ILL Health Care
with no employees. !
[No workers'comp,insurance reg.] 12.0 Other
*Any applicant that checks box 41 must also fill out the section beioyy showing their workers'.compensation policy-.information.
**If the cofporafe officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box 41.
I am an employer that is providing workers'compensation insurance for ray employees. Below is the policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:23 COMMONWEALTH AVE
City/State/Zip: CHESTNUT HILL, MA 02467
Policy#or Self ins.Lic.#1821AExpiration Date:01/0 i/201
Attach a copy of the workers'compensation policy declaration page(showing the policy number andexpiration date).
Failure to secure coverage as required under Section 25A ofMGL 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' s andç'naltie7rPerfur that the inforrnation provided above is true and correct.
• gnature: \. p f , .
Date: f •31 tic;
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.govfdia