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Home My WebLink AboutBLDG-19-002175 —i tvaeaaaaaonvas! I 0 UNIrvrarvI Pldr1-1.wI.4I IJri r6.IINre rLrewut .°!+•.•.%. •••--•••••••_ .,..,._,-,•...-TT C W:BIM 7°_t CITY _Yft!'t l D if ____—._.___ MA DATE__ la" -7/�4PERMIT# .05`/?''�417r JOBSITE � ADDRESS 10 _ A✓_110((1..S ee-Yaf��tdviii OWNER'S NAME, 1'L"dl ]_ IYLL -._--_ -� G01664 OWNER ADDRESS ___ 5f Vie. _ __ _--.------_- TEL (,j ?33 icoaci FAXiz_.._- -- _-I TYPEP OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL El RESIDENTIAL fx CLEARLY NEW:® RENOVATION:© REPLACEMENT: ) PLANS SUBMITTED: YESD NOD t-, _70 APPLIANCES 1 FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER MN_ : 16111 . -KuniiMen MIR ®MIN MNERMt CONVERSION BURNER . - COOK STOVE DIRECT VENT HEATER 1-_-_ _--t DRYER --- - _ FIREPLACE FRYOLATOR _ � , GENERATOR t-- GRILLE 1 1 INFRARED HEATER, _ MK MAKEUP AIR UNITNM M. LABORATORY COCKS ® MI Mil®®��"011111,11.1111111.1MMIIIII ,, —III OVEN t Eli POOL HEATERIII ROOM/SPACE HEATER ROOF TOP UNIT I l TEST UNIT HEATER IUuI' I' I UNVENTED ROOM HEATER �,®, WATER HEATER UM ,_ .) _ _- OTHER ', , , ,, an ..,, , ,_____ _ , it ; policy INSURANCE COVERAGE olic have a current liability insurance or its substantial equivalent which meets the requirements of MGL.Ch.142 YES []NO [] I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ID OTHER TYPE INDEMNITY ® BOND Q 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. -4-- CHECK ONE ONLY: OWNER E3 AGENT E v SIGNATURE OF OWNER OR AGENT 0 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 comps ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# , wS G ATURE 12298 `O\A MPO MGF® pp JGF® LPGI© CORPORATIONQ# 3281C PARTNERSHIP®#1 . _ _ILLC©#1.__-_.____-_I COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE - ir CITY SOUTH YARMOUTH STATE' MA I ZIP 02664 TEL 1508-394-7778 _____I FAX 508-394-8256 CELL N/A �EMAILI accounts payable efwinslowcom Q 1 D64 OiQ/DD V D Y 6.66 6D O LC I6606 C/j 1I16 6.n 6 YSJ b 69066A 6J � � s:; 1)epartiraenP of Industrial Accider�ks -" ►; Office of Investigations 600 Washington Street —� Boston,MA 02111 y www.mass.gov/dia "AO*: `- Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers kpplicant Information Please Print Legibly �_ Tame(Business/Organization/Individual): L 6C•W t�r�$�OW Y1i,,yA9' 0 t��,' Qe ink D ) \ddress: 3 fadan Cla,� v 7,ity/State/Zip: So % 'artmo.,k-% MP Phone#: SUE-399-i'i'7' IVre you an employer?Check the appropriate box: Type of project(required): I am a employer with -70 4. ❑ I am a general contractor and I \ (� 6. El New construction employees(full and/or part-time).` have hired the sub-contractors El I am a sole proprietor or partner- listed on the attached sheet. 7• El Remodeling `��) ship and have no employees These sub-contractors have 8. Ill Demolition ' e working for me in any capacity. workers'comp.insurance. \ \ 9. El Building addition Q� [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions ,t ❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp.insurance required.] .4,. ry applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • 41C � m�eowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. r. o. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. Pitan employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site r 'vitiation. urance Company Name: ,,.) fti k e.ii ��j, t n Ce_ (Thaunetioi icy#or Self ins.Lich!.^'#: I$a i4 Expiration Date: I—1 — aOI9 Site Address:3 Gfrv,mOrel w'eJ411 AR/ C NI City/State/Zip: OtY-1 107 :ach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 3 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 ip to$250.00 a da a ainst the violator. Be advised to.t a copy of this statement maybe forwarded to the Office of estigations the DIA for insura> overage verij on. )hereby certify un a ains a 'penalties o p•juiy that the information provided above is true and correct. natuT - IL Date: 1 al 311 a017 me#: Sug;311- 777X 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 5.Other Contact Person: • Phone#: