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HomeMy WebLinkAboutBLDG-16-005311 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK %" CITY 61 Wiwi-Li MA DATE 31 Z ' 1� PERMIT# /W E,-16`C06 Vr I. JOBSITE ADDRESS 13 eiddock S}• OWNER'S NAME C4Li.rJ GOWNER ADDRESS 2-ct 3 Z Ley 1.6.-' Of, TEL FAX, TYPE OR 16Ano i/:r11.'1 ' Z31toe PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Et' CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: [ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS--, BSlvl 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT —1 OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER INVENTED ROOM HEATER WATER HEATER OTHER 1\ IML4k GA-8 re INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES`E NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ©. OTHER TYPE INDEMNITY ❑ BOND 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 ❑ 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 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 compli ' all Pertinent pr ' ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# 17 SIGNATURE MP❑ MGF❑ JP JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME N14223 'h ADDRESS 7 ti q P CITY �;', 4-IC.L STATE tktvt ZIP Oi p l: FAX CELL EMAIL ~ I MAR 29 2 1E ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES fit- 6/eti- I/Q/6v Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES v COMMONWEALTH OF MASSACHUSETTS "DIVISION OF PROFESSIONAL LICENSURE BOARD OF. PLUMBERS AND GASFITTERS ISSUES TI{E FOLLOWING LICENSE LICENSED AS ; A JOURNEYMAN PLUMBER ''- -4r11 LAWRENCE A MAZZOLA ?�. 7 NONESUCH DR NATICK MA 01760-1041 21202 05/01/16 203669 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER 1 The Commonwealth of Massachusetts Iu-w � Department of Industrial Accidents _:,;,jo 1 Congress Street, Suite 100 7_,�umr. = Boston, MA 02114-2017 „5� www.mass.gov/dia aV Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TUE PERMITTING AUTHORITY. Applicant Information // Please Print Legibly Name (Business/Organization/Individual): /1/4-'((4ZiD(�J Address: ( 1\6/Le Jt 11 Of, City/State/Zip: Ido4k-1"-- 1,144 OCILoo Phone #: (91 - 2-11-01/4-i 03 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. n New construction 2.[E14m a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers'comp.insurance required.] 9. [' Demolition 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.] 10 ❑ Building addition 4.❑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.D'Islumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.; 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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. tContractors 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: L w 2kf s 5 Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: i3 3` dac1-C 5 4" ► City/State/Zip: r141ok:44 144$42 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 certi y nder the pains nd penalties of perjury that the information provided above is true and correct. Signature Al v�4 Date: 3 1 //(o Phone#: (e0- 2.-`fY-ocIa3 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 Contact Person: Phone#: