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Home My WebLink AboutBLDG-25-96 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY'\II\I-MU 4 NIO MA DATE a—1-20 PERMIT#8/-.1)1.9-2S— Q S' JOBSITE ADDRESS 42 MtS�ITM' �tC OWNER'S NAME G l 11 6 A--Pl .G OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL PRLNT CLEARLY.EARLY NEW:a RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO❑ APPLIANCES 1 FLOORS-. MAI 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.000KS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER R G C E IV E D ROOF TOP UNIT TEST FEB 8 7 2425. UNIT HEATER UNVENTED ROOM HEATER WATER HEATER BUILDING DEPAATMEVT OTHER • ✓ By _ in1C� '1.2 fit\-HLa PLC,- Z P,G 1 INSURANCE COVERAGE ,_� I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES nv❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE Of COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY jJ/ OTHER TYPE INDEMNITY❑ 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 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 I Pertinent vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,n ,� t- n k PLUMBER-GAM NAME LICENSE# u��k� SISIGNAh �� c Its3 -� MP MGF 0 JP 0 JGF 0 LPG 0 CORPORATION❑# PARTNERSHIP❑# LLC 0# COMPANYNAMECL-" Lip GC.- �uM, V ADDRESS 13 04 C7ot~9 GTY 1 fL 1 C4-4 STATE MA vP O 26 9- •I TELLs-o8-Li 3 O-0,46 s' FAX CELL��O'—k EMAILPCPc((-PI k 631. 6 MA-1 L. Lc.)f•^ The Commonwealth of Massachusetts W'..,,1111•11111.1 Department of Industrial Accidents �i =M:;l:- 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,.V=, =; •www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPlunibers. TO BE FILED WITH TIT PERMITTING AU rnORITY. Applicant Information Please Print Legibly Name (Bt:sinesslOrganization/Individual): Address: City/State/Zip: Phone #: Are you au employer? Check the appropriate boz: I Type of project (required): I..i I am a employer with ._r__�_ employees(full and/or part-time).* 7. ElNew construction 4-1 I am a sole proprietor or partnership and have no employees working forme in $. ❑ Remodeling any capacity, [No workers'comp. insurance required..] 3.0 I am a homeowner doing all wort:myself: [TIo workers'comp. insurance required.) t 9. E Demolition 10 Building addition 4.E 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 .Q Electrical repairs or additions proprietors with no employees. 12.El Plumbing repairs or additions 5.0 I;gym a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.r ROC/repairs These sub-contractors have employees and have workers'camp. insurance.; 14.n Other 6.1 We are a corporation and its officers have exercised their right of exemption per MGL c. — 152,§1(4),and we have no employees. [No workers' carp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers' compensation policy inforwation. t lioniftnwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit 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: Policy#or Self ins. Lie. #: Expiration Date: _ 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 1\MGL c. 152, §25A is a criminal violation punishable by a fine up to $I,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 above is true and correct. Signature: Date: Phone#: . i 1 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 #: