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Home My WebLink AboutBLDG-16-005920 .• 1.— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK tiii:Wr-: if CITY �y(",1 res.()u.k)--. MA DATE 4-WI-i 10 I PERMIT# ix--4, 00 cv020 JOBSITE ADDRESS, -1 6RDAd zAS 1 LAi I OWNER'S NAME I RoGOR lc ovvC G OWNER ADDRESS �_ —-- _TELr FAX 1 TYPE OR OCCUPANCY TYPE COMMERCIAL A EDUCATIONAL ri RESIDENTIAL PT PRINT CLEARLY NEW: RENOVATION: 'V REPLACEMENT:,__: PLANS SUBMITTED: YES L N00 APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 I 12 13 14 BOILER BOOSTER L._— _—_ -� CONVERSION BURNER COOK STOVE ,- ...4____,f ____v__ __ _ _ __ .. _ DIRECT VENT HEATER 1 DRYER ' _ _ -_ FIREPLACE i FRYOLATOR _. FURNACE • I — t___::._.. � — • GENERATOR GRILLE --Ir. __—Ir 1.: _ INFRARED HEATER LABORATORY COCKS 4_-_, ____ _�__ , _ -----;., ' - MAKEUP AIR UNIT '_ .._ I OVEN I POOL HEATER ROOM/SPACE HEATER r—. ROOF TOP UNIT F_ TEST 1I UNIT HEATER i UNVENTED ROOM HEATER 1 WATER HEATER ..- OTHER — -- - i 1 r INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES (f 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the]General Laws. ./�, ""l PLUMBER-GASFITTER NAME; 6 CA N i L W G .-( Ir�j 1 LICENSE# la v) �'✓ SIGNA E MP'>>, MGF JP JGF^� LPG' CORPORATIONA [ j# 1 1 a(, i PARTNERSHIP'.)#L,_ _ I LLC Q#1— I __ ADDRESS C B c' 23� COMPANYNAME:; ct wdeR 1 y. and So,AS .__a. __. _._e _ CITY FI V UkT'{1 pG,k h, STATE j f\6\I ZIP 1 ()i g. f 1TEL '1� i'C)-' r°I:.CL.� -... —�-- 4 FAX CELL EMAIL[ eln c ppwQ�C(J Ah) Sl`^ ... .t ,," • l� I �� The Commonwealth of Massachusetts ��—*'—_ � 1, Department of Industrial Accidents __'�►= 1 Congress Street,Suite 100 Boston,MA 02114-2017 ,,,= www.mass.gov/dia 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):POWDERLY AND SONS PLUMBING AND HEATING, INC Address: P.O BOX 235 City/State/Zip:NUTTING LAKE, MA 01865 Phone#:978-663-0164 Are you an employer?Check the appropriate box: Type of project(required): LID I am a employer with 22 employees(full and/or part-time).* 7. ❑New construction 2.El 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.]' 9. ❑Demolition 10 0 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.❑Plumbing repairs or additions 5.0 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.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:ARBELLA INSURANCE Policy#or Self-ins.Lic.#:0055161015 Expiration Date:10-31-2016/ L Job Site Address: 6 U(.t ��I Gt t^ �' City/State/Zip: i c't t rn 4 vk n 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 under the pins and penalties of perjury that the information provided above is true and correct Signature: JAA7 `f Date: 1 I r Phone#: 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#: !, �VIVIIYIv...r.-,..._ r',IYISION QFPROFESSIONALi- 11 - BOARD Of • . PLUMBERS- A O GASF I TLER.S. ISSUES THE FOLLOWING I DENSE LICENSED'. A:S A JOURNEYMAN PLUMBER g BRI:AN- G POWDERLY.: ;0 PO BOX 436 2 NUTTING LAKE MA 01865-0436 23513 > 05/01/.16 _. :; . 214746 LIOENSENUM-ER EXPIRATION PACE.. .. 5,:- • .N n R a, COMMONWEALTH OF MASSACHUSETTS. DIVISION,OF'PPRQFESSIONAI"; IOENSURE BOARD OF PLUMBERS AN.. GASF ITTER::S<, _ ISSUES THE FOLLOWING :LICENSE . REGISTERED AS A PLUMBING CORP BRIAN POWDERLY 4 POWDERLY Ix SONS PLUMBING & HEAT! 1. 10 OLDE WILLS I DE I U J BILLERICA . ..MA 01821-1715 I ' 3126 05/2 1/:1.6 ... 214455 # . UIOEAISE NUMBER :..,_: PIRA: RATE S,RIAL 8EB coMM°"w >�rH of .. ..::" O ISJQ qF p MA O R>DFE S4SIONq L �U5 tSfia pLUMBE B A 17 � tct;A[S( .�:: ISSUES THE F GASFITTER�.... .tCE : OLLOWIN :: lSE:D AS t I1;ENSE A MASTER PLUMBED.. .a; BRJAI4GPOWDERL? PO BOX 43 1 UTTI�jG LAKE ;+ 12026 �1A 0186�_0436 " Ai shy . a.5/01/16 ;� r' 745 �xplp. 214 • • • • V, Commonwealth of Massachusetts Department of Public Safety License: PM_298258 'ipefitter Master PP BRIAN G POWDERLY 10 OLDE HILLSIDE AVE BILLERICA MA 01821 • Commissioner expiration: 04/24/2017 Massachusetts Department of Public Safety • 17 Board of Building Regulations and Standards • License: CS-078476 Construction Supervisor tat BRIAN G POWDERLY 10 OLDE HILLSIDE AVE BILLERICA MA 01821 �..�n Expiration: Commissioner 04/24/2018