HomeMy WebLinkAboutBLDG-20-000175 &_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-,��- CITY ___, ' �! ' _W_ 8 MA DATE b 1 f ' PERMIT# %%//)�1'O CV 4' r
JOBSITE ADDRESS.21 ,y�f ci, 1�✓i' Sc,;tln 4%✓�sr.. LOWNER'S NAME i____ _22G'•__g
GOWNER ADDRESS 1 ' d!'t�'' . r, • ti �`v1 k ,((f TEL�C `.�C? JFAX �__._„J
TYPE OR CCUPANCY TYPE ' COMMERCIAL ci EDUCATIONAL f RESIDENTIAL')
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CLEARLY NEW:LJ RENOVATION:El l REPLACEMENT:Ln PLANS SUBMITTED: YES NOL J
APPLIANCES-1 FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER L__- L ( -I._._s.;I- J(-T-`I. _. 1_,__ I`._TI „IL__1-- 1__ `L _ ET-
BOOSTER -
CONVERSION BURNER L_IL r 1 I I I. h L_e.. I I L_ 1- IL __I
COOK STOVE .1_ _1_,n__I___I__,____I__._. I_ 1._._...L.P.....a.�,IL I..___. I.„_..�.�._ ..I... �,.I,.
DIRECT VENT HEATER (..�_. _I._._ �:1__�_ r T I._.__.'I-._._m I I__ r_._._J G._... L!L...._._'��..�..-. I,.____
DRYER I_- I-____[w..._t i_ —L.�_1..�-_J[.J i I !I-.___i I
FIREPLACE ri I=L __._1I__ I__.a_.'I, _i1_ . r_, __._1=C_., _L„ I�-._ 1--_-,1-�.
:_-FRYOL"ATOR ___._ - .
FURNACE — _
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GENERATOR I I I I I I _ _I__.. ., I. --_ I__ h -_._ I_._ ._I___..a. I_.
GRILLE =
- INFRARED HEATER _ _- _ �_ J, _- —__ _E___7( _ ._ C_ L
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LABORATORY COCKS . I+ I ; I _
MAKEUP AIR UNIT L , 1:_ .�, ( -,..�;t�. . L,-._�., ___�[ e.e..i lE L 1..�.,J I .. =.�I ,. __
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ROOM 1 SPACE HEATER L P I_, _ti I. .___ ,L — 1--1 11_ _ I..�.-..J�.�,'I _ __1 I_�.,.__..J C
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UNIT HEATER 'I �;( - -- _ _. '� = ��- � _ '�
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UNVENTED ROOM HEATER L___ I 1 r I I 1 [,_.—?(JL ; �� I..a.___J' _ I _ 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 LJ NO EJ
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ti1 OTHER TYPE INDEMNITY L[T1 BOND la__
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 Fi AGENT H
SIGNATURE OF OWNER OR AGENT., ___
rJ I hereby certify that all of the details and information I have submitted or entered regarding this application are true and-a`ccurar to th b st of-my knowledge-- -
?' and that all plumbing work and installations performed under the permit issued for this application will be in compliant i a1YP rtine provision of the
V Massachusetts State Plumbing Code and Chapter 142 of the General Laws.1/4
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t- ;v PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE
_ MP 0MGF EJ JP ID JGF LPGI
11
® 0 CORPORATION El# 3281C PARTNERSHIP Ej# 1 LLC 11#
COMPANY NAME: E,F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 0
0
FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM
The Commonwealth of Massachusetts
Department of Industrial Accidents Ft MINNOW
�°z = l Office of Investigations
S
Lafayette City Center
a
2 Avenue de Lafayette,Boston,MA 02111-1750
L'"u two www.inass.gov/dia
\Workers'Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
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: Business Type(required): ------ ---
1.111-I am-a employer:wit 9.0 —employees-(full and% 5: 0`Retai1
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
3.11 We are a corporation and its officers have exercised - 9. ❑Entertainment •
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp.insurance required]**
4.IllWe are a non-profit organization,staffed by Volunteers, 11.0Health Care
with no employees. [No workers' comp.insurance req.] 12.111 Other
*Any 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
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. 1
Insurance Company Names ARROW MUTUAL INSURANCE COMPANY i
Insurer's Address:
1
City/State/Zip:
Policy#or Self-ins.Lic.#1909A 01/01/2021
Expiration Date:
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 fief thtie ins and penalties of pef jury that the information provided above is true and correct: i
1
ignat�tref- -- " Y ``l <� 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.
City or Town: Permit/License# I
issuing Authority(check one):
L.UBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board
>.fl Selectmen's Office 6.DOther
•
;ontact Person: Phone#: