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gEIX. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESSti 4_i 't jj,'? . i t (� , ;r;re,, ,OWNER'S NAME jklat:41. 4-14, Cif i
GOWNER ADDRESS \411 'il ft1 r I Vt TEL "
TYPE OR (�,ttC �j 1
PPE T OCCU�AfVCY TYPE COMMERCIAL fl EDUCATIONAL Li RESIDENTIAL
CLEARLY NEW:1J 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 L _- 1 '1TI-217__.-I 77 !1__ f I -_,II '
BOOSTER
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CONVERSION BURNER t_ L .,L. 11--. . :I. . IT--1. ._ ,1-- I__ I. _ I -..�I.
COOK STOVE --
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DIRECT VENT HEATER L I� L�:- 1 _71 I I.. _- L-_�i E _ r :L- [L n
DRYER I L.� L _I- _I L-. 1 L_-- L.Li i,._, i1::. _. L..._ I
FIREPLACE L-�____r-- _.-I I ,..-I E. . :L_.. 'L. 1 I_. __11. ' _-i f . [_... I - „N j!h �...I.._ ._
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FURNACE Li ., L-- ."-. -_
GENERATOR 1_,....,:1---- I- -'i 1------ _ I _._._ I I ___ I_ I I__, . L-m-
GRILLE LTA
• INFRARED HEATER I h_--'r -:[- _ I _._ I. L.., . f__.__ L�_.._-_1.___,_.Ei 1 _ .., _.__:
LABORATORY-COCKS 1 'I I_ I L ..__ I I �_. L ( I__ 1__._1 G-._.�..1 L I I_Ls,. L". _
MAKEUP AIR UNIT L =I I . i�. . � .,E._-. C ,.,T -1- _ 1=Lf.-ax(I-� II�--e,l .71.,
OVEN - =I _-__J I_._..,;I____1 I i I_,(I. : -_-i C I I'I 1 I E
POOL HEATER I C - - __i -- ---
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ROOM 1 SPACE HEATER L� .�
ROOF TOP WHIT � -.1 -, I 'r- I .. I L �,_._L_,. L r_ L L IL T,L,DL. �. [
TEST L �T- [=_L _L ..a::w'f _.1-i[ ..!I__.,. ,1....,_��_C--L_-..�s.._ __._...,(-
UNIT HEATER - - � -- -��� � � �`- � ��-�I I 1_ r _.. I I �i L--_ , L_ t r °I- Li�.L_._J_
UNVENTED ROOM HEATER L..,, I ,, I t n C -L _1_._ _2 L. ..„ -:2 L., , I,L_b.., L ,J
WATER HEATER ,- -_.I I I i I L I 1 I I_ L� L ___
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�� �� INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES E I NO i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY El, BOND Li
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 L..,i AGENT L .
r ',S 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-acburat"to'thhe b-st of-my knowledge-- -
C and that all plumbing work and installations performed under the permit issued for this application will be in compliant i a YPprtine provision of the
J Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `/
k
- ,-- PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE .
,` MP 0 MGF® JP 0 JGF ID LPG'0 CORPORATION I i# 3281C PARTNERSHIP D# 1 LLC D#
. .. CJ COMPANY NAME: E,F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL ( g- �
FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM
1
The Commonwealth of Massachusetts
Department of Industrial Accidents
)t- t i,f Office of Investigations
< Lafayette City Center
2Avenue de Lafayette,Boston,MA 02111-1750
•6 www.mass.gov/dia
'Workers'Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
I
Business/Organization Name: E,F.WINSLOW PLUMBING& HEATING CO, INC.
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778
Are you an employer?Check the appropriate box:.., " ___ BusinessT ere aired —�-
_.1.E- I am-a en.' loverWith-91 ___ em l0 5. Retail`—�
p yees`(fii11 and/----
or part-time).* 6. []Restaurant/Bar/Eating Establishment
2.❑-I am a sole proprietor or partnership and have no
7- ❑Office and/or Sales(incl.real estate,auto,etc.)employees working for me in any capacity.
[No workers' comp.insurance required] 8. ❑Non.-profit
3. ^_ We are a corporation and its officers have exercised - 9. 0-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, 11.❑Health Care
with no employees. [No workers' comp.insurance req.] 12.0 Other
*My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Names ARROW MUTUAL INSURANCE COMPANY
•
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.#1909A Expiration Date:01/01/2021
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under§25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up
:o$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
he DIA for insurance coverage verification.
do hereby cer /e the ins and penalties of perjury that the information provided.above is true and correct.---_ -
f ignatiiri?. y — /V' --. . Date: 01/02/2020
lone#: 508-394-7778
Official use only. Do not write in this area,to be completed by city or town official.
4
City or Town: Permit/License#
Issuing Authority(check one):
LQBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.CILicensing Board
CISelectmen's Office 6.DOther
i
ontact Person: Phone#: