HomeMy WebLinkAboutBLDG-18-004547 \ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO PERFORM GAS FITTING WORK .
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JOBSI T E ADDRESS..7_4QQ_ au p.._ a_,P--T-r OWNER'S NAME iLklifellipart�- f i)
GOWNER ADDRESS V,f7� -01 =i 7 ]( ►lNh.►J1,E —FAX -- _. --
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL E, RESIDENTIAL0
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CLEARLY NEW:D RENOVATION:L:1 REPLACEMENT:? PLANS SUBMITTED: YESD NO1
APPLIANCES 1 FLOORS--I FBSM 1 2 3 4 5 6 7 8 I 9 10 11 I. 12 13 I 14
BOILER -`—'{ __ _
BOOSTER ~ `- M" _ _ _
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CONVERSION BURNER (w �`- ' '" I-� �` ry _1_
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DIRECT VENT HEATER ].:I_7,_ FI: 7il -•l- 1-7 L. _.L'CT:: :E� ,�_•I.:..w..,i.._-.L_ :I .
DRYER (�:_ = .. __. - - �.I...-. ._... o _.,__
FIREPLACE I i( I- I 1 �.. -Y- 'Lz_._T? :. 1 I- l---- y 'I__•. -ilk--_ I
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MAKEUP AIR UNIT I� (� L: �1. --!L .7. -.IL A.-'I_,�,_�I,� ..L+,I �..'•:I�� :I. .-.�I:..--'!1__
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POOL HEATER L- 'I. 17--L L-- -;1 )1 I----:T.T..". .,C.,_- 1... ;L. _+..I.- .
ROOM I SPACE HEATER I,. 117. 1- --'.I. �r Y1I _..:I. _=;1� I__ -_;L..,_.'L7_.�I._:-. :___--.C- -,1. _1
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UNVENTED ROOM HEATER _�i L I. .2,1-__i IT I. _7:` •1�...._•L..-.._••I_,._ .. 1. 1 -----..1 --1-' .'
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INSURANCE COVERAGE I
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Ea NO
60
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW _
LIABILITY INSURANCE POLICY D OTHER TYPE INDEMNITY D BOND E -a-
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 0
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 an 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 complian e with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME'STEPHENA.WINSLOW I LICENSE# 12298 a SIGNATUKC -
MP ID MGF O JP 0 JGF O LPGI FL- CORPORATION( i,#1 3281 C _ 1 PARTNERSHIPD#L. ,j LLC 0#=
COMPANY NAME: EF WINSLOW PLUMBING&HEATING z }ADDRESS 8 REARDON CIRCLE ___
CITY I SOUTH YARMOUTH H s__ ,-. . STATE L MA 1 ZIP 02664 A WW�JTEL 508-394-7778 _",�n l�' 0-
.....__.
FAX 508-394-8256 1 CELL NIA _ �I !EMAILLaccountspayable@efwinslow.com ___~ M _ N_ rl
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The Commonwealth of Massachusetts
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Department of IndustrialAccidents 1 Coness Street,Suite 100
Boston,MA 02114-2017
,,,,.o�, www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE ki.LED WITH nth:PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/OrganizationName:E. F.WINSLOW PLUMBING&HEATING CO.,INC
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH,MA 02664. Phone#:508-394-7778
Are you an employer?Check the appropriate box: Business Type(required):
1.❑✓ I am a employer with 10 employees(full and/ 5. 0 Retail
or part-time).* 6. 0RestaurantBar/EatingEstablishment
2.0 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
3.0 We are a corporation and its officers have exercised 9. ®Entertainment
their right of exemption per c.152,§1(4),and we have 10.0Manufacturing
no employees.[No workers'comp.insurance required]"* 11.0Health 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
organization should check box#1.
lam 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:23 COMMONWEALTH AVE
City/State/Zip: CHESTNUT HILL,MA 02467
1821 A 01/01/201
Policy#or Self-ins.Lie.# Expiration Date:
Attacopy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi r the and enalties o perjury that the information provided above is true and correct.
° l 1
Signature: ` Date: i 2. , 3I / t F
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(circle one):
1.Board of Health 2.BuiIding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.govldia