HomeMy WebLinkAboutBLDG-20-004042 . \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY I ...\ jccjtt. , MA DATE _ , PERMIT# _0�y_0o)y���
JOBSITE ADDRESS
gat" OWNER'S NAME ..� . .y r� . , ..
GOWNER ADDRESS TEL ^; 7( FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL Lj EDUCATIONAL RESIDENTIAL" '
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CLEARLY NEW: RENOVATION: REPLACEMENT:,,. r PLANS SUBMITTED: YES ' NO
APPLIANCES Z FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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POOL HEATER
ROOM/SPACE HEATER
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UNVENTED ROOM HEATER
WATER HEATER
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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 NO
C I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
5 LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY BOND 1.
�V OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
0 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
2
CHECK ONE ONLY: OWNER AGENT
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 accurat to the b st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complianc a P rtine provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • `/
PLUMBER-GASFITTER NAME[STEPHEN WINSLOW LICENSE# 12298 SIGNATURE
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MP i MGF' JP JGF LPGI CORPORATION i # 3281C PARTNERSHIP LLC #
COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH , STATE MA ZIP 02664 TEL 508-398-7778
FAX 508-394-8256 CELL N/A ;EMAIL INSPECTIONS@EFWINSLOW.COM i
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Z The Commonwealth of Massachusetts 257 __0. O en, t�&-
D,,,,:. .. _ ,,.... epartment of Industrial Accidents g „, tAY�°�'1
�•,i,) , Office of Investigations
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Lafayette City Center
2 Avenue de Lafayette, Boston,MA 02111-1750 ��� e'. .
�M � www.mass.gov/dia v.?)
Workers' Compensation Insurance Affidavit: General Busines s
Applicant Information Please Print Legibly
Business/Organization Name: E.F. WINSLOW PLUMBING & HEATING CO, INC. 11\
Address:8 REARDON CIRCLE
City/State/Zip: SOUTH YARMOUTH, MA 02664 Phone #: 508-394-7778
Are you an employer? Check the appropriate box: 1 Business Type(required):
1.0 I am a employer with 90 employees (full and/ 5. L_I Retail
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. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]** 1 1 ❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 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 I I
organization should check box#I.
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:
City/State/Zip:
cY 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
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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of
` the DIA for insurance coverage verification.
-... I do herebyl}y-cme the �in�s�d penalties of perjury that the information provided above is true and correct.
\ / lr Signature: Y Date: 01/02/2020
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(check one):
1.0Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.0Licensing Board
5.0 Selectmen's Office 6.DOther
Contact Person: Phone#:
www.mass.gov/dia