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Home My WebLink AboutBLDG-17-000576 e1 ., 1b. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Vr' CITY: y 0 t Wi t-o-11A Pc !4 MA. DATE: -1 f�5 �4t 7 v J J 6 % S.7L JOBSITE ( atea ADDRESS: � C � 1,�I• OWNER'S NAME h e I bi i e- 1--1 jivC-C' GOWNER ADDRESS: /`I 7.rE'y or TEL: A't 1) -O7CrIFAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMI I IED: YES❑ NO❑ APPLIANCES-1 FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER4 _ BOOSTER CONVERSION BURNER , COOK STOVE DIRECT VENT HEATER DRYER _ FIREPLACE FRYOLATOR . FURNACE GENERATOR GRILLE Iv) INFRARED HEATER 1 LABORATORY COCK MAKEUP AIR UNIT c3 OVEN ," POOL HEATER ROOM f SPACE HEATER \I ROOF TOP UNIT fi TEST UNIT HEATER I4.1 UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0 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 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT 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 comptan with all Pe 'pcnt' provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: j r;'liA61, J. (1;7,1 LICENSE# /02 N� /i SIG TUR COMPANY NAME: , ,V(V/ 1ili 4 ADDRESS: 3a 1/f _ CITY:�1 i(j}\ 9 STATE: 11'Df"- ZIP: �- ) c FAX: `b �i-35)3 TEL ) u J 1 5 1 CELL:--) EMAIL: /A p)u Irn.1-Ii h Ns 6 ellr r'i n- MASTER❑-JOURNEYMAN❑ LP INSTALLER❑ CORPORATION Er(.. 74 PARLNERSHIP 0# LLC 0# E M n/L i),DArte-ss : i! r-kiij,vi_i elL.0,-A 1,1 i N.. ' v ea e . in e-f----, ) e 7Ql g5-d 5 i �o 4 h �'1 The Commonwealth of Massachusetts ► �h Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.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): 0 ' Address: &I �#— City/State/Zip: 774.1NftiVitr— �h -��' �� one#: . )1� � •�' �� - Are you an mployer?Check the appropriate box: Type of project(required): 1. am a employer with employees(full and/or part-time).* 7. New construction 2.0 I am 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.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.E Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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: / i / - J Policy#or Self-ins.Lic.#: y O O 7(_( ( Expiration Date: '7 / / ' Job Site Address: City/State/Zip: 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 certify under the pains and penalties of perjury that the information provided ab ye is tru and correct. Signature: . `✓ Date: ` (� Phone#: �t d Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# r. Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Phone#: Contact Person: III - 44' • I _ • - Li" t t • ----.- _- _f-' 1 t... W TH OF ;r<e�- <OMMON E. � DIVISION OF PROFESSIONAL LICENSURE PLUMBERS A YGASFIT ISSUES THE FOLLOWING ENSE t AS A MASTERPLUMS>=R 1GOISEMICHAEL J GRAY 12 BACON ST MA: O1730-2403 • 12426 0510112 018 48947 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER