HomeMy WebLinkAboutBLDG-20-006064 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Y=• CITY �"c",fti .�— `•�[ t /2 ' PERMIT# f )C'v�~ '4.67'`!
���._� MA DATE
JOBSITE ADDRESS LA i h19ti ire ;; OWNER'S NAME
Gth4 ER ADDRESS
TYPRI E OR OCCUPANCY TYPE COMMERCIALF.] EDUCATIONAL L_ j RESIDENTIAL[3—
NT
CLEARLY NEW:L i RENOVATION: REPLACEMENT:3 — PLANS SUBMITTED: YES L NOD
APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER [ L1171177_I 7I— I� 11- !(- r I-- GII— I_,_..__,fE -_ 'I,.
w�..m L L la...... . L f__ � (.,. i I ,K..,.. L. ...I I, .. 1
BOOSTER _
CONVERSION BURNER --
COOK STOVE
I _.�r, I_� r___�._ I -__ I__ :i i
DIRECT VENT HEATER ,I I
DRYER { I ( I I I IM I
FIREPLACE
T 1- r_LH n L._� !I. I „ �I �� x_�r _„,1_,�..j
FRYOtATOR _ I —11 I—'(._,..__s1 '1 11_:1
FURNACE ( I C f.., L I._ i��I I :1_ 'I_ I L_ Iw. _.. I_,
GENERATOR I...._.� I I-----'I_ !- -I„_ —I— L - L_. ___ I_ _ 'L I.., .. PHI___,
GRILLE � .n_ I - - I— -- -- - -
I_.; I I I
• INFRARED HEATER I I- I` C_H I___ _.-
LABORATORY COCKS... I ='1=j I__ _,L�_. l I.,- _ .I _ : I I I I LH I Im
MAKEUP AIR UNIT I 'Ia_ C,, I F 7 11_..�..w.i I_
OVEN - I 'I I 1____..
POOL HEATER C�r— �
-
ROOM/SPACE HEATER
ROOF TOP UNIT I L.I. I_ _L I I I r
TEST 1 r__..C _xa �'1_ .__'La�_ (._ ( i�. �L C.._.�QI.:LA:I_-
UNIT HEATER I I_ I I Ix L I L L__ i _l�_rl( _-__:r___y . LI=
UNVENTED ROOM HEATER I� _ i� C - C.• __.C i C__ E :-:
WATER HEATER r- r -"La
OTHER
_TT:-L L. ._,I_._ i.�_.._.'r- T(— -. ( L„ . `L =E-DL_, _. r r
I._ , I ! i r r , , I ��I _i1 I--
_I
!. I ! I I I_ ._ I i _z l I I I . •I
i I �. L !— TIT. !� !_e__ !.� i I ;- -r._ � . I _.-..a
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES % i NO L1
I IF YOU CHECKED YES,PLEASE INDICAi ETHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY :El OTHER TYPE INDEMNITY r BOND La_,I
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 Li i 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 and aceu`rat to tlre-b st of-my knowledge- ••
and that all plumbing work and installations performed under the permit issued for this application will be in cornpli'anncc i a1YPPrtine provision of the
n�..� Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � !f%1 •
PLUMBER-GASFITTER NAME STEPHEN WINSLOW
r LICENSE# 12298 SIGNATURE
MP D MGF® JP El JGF® LPGI D CORPORATION # 3281 C PARTNERSHIP D#L_I LLC E#
COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS'8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP[02664 TEL AO 3tii r P�
FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM
GAr
The Commonwealth of Massachusetts
�/ Department of Industrial Accidents
' Office of Investigations
Lafayette City Center
` 2 Avenue de Lafayette,Boston,MA 02111-1750
F iv
N. www.mass.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 L___ --
£ity/S tate/Z p:POUT ARMOUTH, MA 02664 Phone#:508-394-7778
--
Are you an employer?Check the appropriate box: Business T yP e fqnire �_
re — —
1.0 e-I am a ern lov s wit i-90 fill eir� 5. R fe ail y
p and/ __ .
.- or part-time).*
6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no
7. ID Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. ❑Non-profit
3.0 We are a c_ _ orpora�ion 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.EllWe are a non-profit organization,staffed by volunteers, 11.❑Health Care
_ with no employees. [No workers' comp.insurance req.] 12.❑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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:
1
City/State/Zip:
_ __ li — ,
Policy#or Self-ins.Lie.#J 909A-
Expiration Date:01/01/2021
A-ttacaa 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 i
;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 ce a the ins and penalties of perjury that the information piovided.above is true and correct." _ 1
ignatur - `/j',f�* G .,...p�.,--- 01/02/2020
Date: I
ione#: 508- 94-7778
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(check one):
lflBoard of Health 2.❑Building Department 3.0 City/Town Clerk 4.❑Licensing Board
;.❑Selectmen's Office 6.❑Other
•
;ontact Person: Phone#: