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HomeMy WebLinkAboutBLDG-20-003129 • • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK � _ 0 • CITY D- (1", .L.. ,_ MA DATEI_IJ .s 1.1.9 1 PERMIT#e_ -ad'CO $i.. r JOBSIT ADDRESS EM R E r ui Ii1it OWNER'S NAME ra'``ri_�• ;♦ ranagam G OWNER ADDRESS - XfL��_. i . � � 1 TEI.I, "_ .` '1316„..IFAXI ------------ i TYPE OR OCCUPANCY TYPE COMMERCIAL O EDUCATIONAL 0 RESIDENTIAL PRINT (--( CLEARLY NEW:Q RENOVATION:0 REPLACEMENT:O - PLANS SUBMITTED: YES 0 NOD v APPLIANCES 1 FLOORS-4 EMI 1 2 © 4 © 6 0 8 s 10 111®® 14 (--ir BOILER --- -` ®�I®ILliii BOOSTER � I_ 1L� M�11111111•Will -_-- WIRWM CONVERSION BURNER IILNIIIMINNININ® ®® M MINIM 1.r) COOK STOVE I EMM Mai l M u , DIRECT VENT HEATERIM ®®®(�I- -_.I L....---._I-I®IM�W .NL _INAM��I®® ® I �FM mil K) DRYER .FIREPLACE ®I �� ......i..___._I�®® WIM®® FRYOLATOR I.- - U(M®MMM��-- [�M® - ter ►— _ - _. __. _II____, _-_ I _I --- _ IIIM -) FURNACE - - GENERATOR, L .-_.1......__.--® �I_ �® —_.1=1.........._1 GRILLE IIM�1.M®®MIMI®I_miMWN...... _ IIII INFRARED HEATER unI m®®®®®nium®w�I- - J LABORATORY COCKS MFM NAJ®LM_ MM ®NINM I MAKEUP AIR UNIT ® L.- ®�L�JINIMIII��� �®� OVEN ® 1iORMI®IMIIINIM®I®IIIM ®I-- POOL HEATER mImwm Iw-mm® m wa 1 ROOM I SPACE HEATER I ®I�_�MMINNWOMI®SililLMIN ®M1=-..._I Room-op-min- ------.------- L�®®®�M MIII®IM®I 1--- -- TEST mtI mi u II mM UNIT HEATER Mt I-M M MMENI MMI®I Ell UNVENTED ROOM HEATER MMINI® NOM®®=0®OR I. - '1 WATER HEATER _ NNIMILMINMIMMMAINIIIMILIMMMIIIIWIL '1 OTHER ..: .. .-.II�_�®®L. ._......I®®®L......_I _ _1®�®�.' i II . .1 - ®®®®®®hl®1 . -----J E--....Ik . . . ......__. .::IMF -. .... i®=®®f ►tmt I=®mil-_—_J INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO [ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW i LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY O BOND E] • L> •OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the TZ Massachusetts General Laws,and that my signature on this permit application waives this requirement. , • CHECK ONE ONLY: OWNER© AGENT L.,:I 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. I 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- .e with all Pertinent provision of the •Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW- •-. --_,_ , . LICENSE# 12298••_ . SIGNATURE MP 0 MGFO JP 0 JGFO LPGI© CORPORATION #I3281C.___ . I PARTNERSHIP O#I . _ • • 1LLCDI_ ._.... COMPANY NAME:I EF WINSLOW PLUMBING&HEATING. -• .I ADDRESS 18 REARDON CIRCLE - . .... •.,.. . CITY ISOUTHYARMOUTH. . .., .. _,.__.._____ __-_,.I STATE[ MA,'1ZIPI02664- __- JTELI508.394-7778. , _ .. _ •__I__ , FAX 508-394.8256 CELLI NA ., IEMAILI accountspayable@efwinslow.com I G %50 rf70 The Commonwealth of Massachusetts = /, Department of Industrial Accidents 1 Congress Street, Suite 100 _;; E= ' 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):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: Type of project(required): LID I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction 2.❑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.]t 9. El Demolition 10 Q 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.Q Plumbing repairs or additions 5.El I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.EIRoof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§I(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:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins. Lic.#:1909A Expiration Date:01/01/2020 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 and a pai s end pen Ities of perjury that the information provided above is true and correct. Signature: �° -^-�. �/1_ Date: 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.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: