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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I_ aiza_A ____ _ . MA DATE 71.?„...//t.q PERMIT 640.-g6La0 sc-;V
JOBSITE ADDRESS lin& /e..,RTZ'onpvii, OWNER'S NAME -1,,,C.5 Bit ffj. __
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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 i:,,,I NO .
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY Ej BOND El .
•OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts Geneial Laws,and that my signature on this permit application waives this requirement.
' - CHECK ONE ONLY: OWNER ID AGENT El .
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 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 compi ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
43 ,,, (ii-14.41A42A
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v% PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW ...._ LICENSE# 12298 . SIGNATURE
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0 0 MP ED MGF I:] JP 0 JGF El LPGI Ei CORPORATION 0# 8281C__ _PARTNERSHIP 0# W Ott _. . _
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COMPANY NAME: EF WINSLOW PLUMBING&HEATING.., ,ADDRESS 8 REARDON CIRCLE
CITY SOPTHY.AIEZMOUTI-I. . ._. ._._.________,____„I STATE l_m_ 'ZIP 92q4. _ . TEL 54:39477778, . ... ..._.,. ...,...,:_.
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FAX 508-394-P5q I CELL N/A .. EMAIL appount9 I
ayable@efwinslow.com _
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The Commonwealth of Massachusetts
r � 1, Department of Industrial Accidents
"� 1' 1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):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:
Type of project(required):
1.17]I am a employer with 88 employees(full and/or part-time).* 7. New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
10 Q Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Policy#or Self-ins.Lic.#:1909A Expiration Date:01/01/2020
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify and a pai s ynd pen Ities of perjury that the information provided above is true and correct.
/t/ o
Signature: °� r.��, Date:
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.Electrical Inspector 5.Plumbing Inspector
6.Other
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Contact Person: Phone#: