Loading...
HomeMy WebLinkAboutBLDG-19-000038 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,,p o g �\ • CITY YtaLtVl filth .___ MA DATE_6/__� ..,L la_ PERMIT#/06.1 JOBSITE ADDRESS 11.0 1.-_("Mil Cf q_1edv....____ OWNER'S NAME Sto+4- 1L14 4P(- GOWNERA`DDRESS I33j5QT�i.fA(1 �11� t"1;I1 R�..__.. TEL,SO'_sg�6 lt4 --_IFAX�_ TYPE OR pp��vv��T((��'� I t 0 3 PRINT O�CTJI�ANCY TYPE COMM4RCIAL( EDUCATIONAL 0 RESIDENTIAL CLEARLY NEW:Q RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES© NOD APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I t It H I I I_ I BOOSTER J J I CONVERSION BURNER _-_- I I' II !- COOK STOVE I ____- 1 ( li I d DIRECT VENT HEATER DRYER j iJ III ii 1 i1 1 �1 FIREPLACE L --. J I I I if FRYOLATOR I. t� I 0 II I FURNACE L IF 1 I l 1 , GENERATOR I Y N Y l 1 ' ,' GRILLE __. I I I. I[ II_ II I II INFRARED HEATER ]( I I 11 I LABORATORY COCKS —1i ' it MAKEUP AIR UNIT I I 11 I «— _ OVEN t—� — A POOL HEATER- I ) L ROOM I SPACE HEATER �1� 1. I I = ROOF TOP UNIT 1 1 I--- TEST _. UNIT HEATER' ,' _ __ ll I UNVENTED ROOM HEATER ___ ) ll � i i . WATER HEATER -_i 1 �' i OTHER - j ; ti ff ---g. _ ---U . ._.._ T-- �T —J' I I _l____1L_ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO 11 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LJ OTHER TYPE INDEMNITY 0 BOND L OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the v Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ 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 nd 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 ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C'- PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW ! LICENSE# 12298 SIGNAT RE t MP Q MGF® JP© JGF® LPGI® CORPORATION Q# 3281C _ PARTNERSHIPD#L _ I LLC Q# , COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE , CITY SOUTH YARMOUTH STATE MA ZIP 02664 T_ _ TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com /Y1 - The Commonwealth of Massachusetts 1 l ' Department of Industrial Accidents • 11i 1111 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: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. Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no ❑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.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees. [No workers'comp. insurance required]** 4.ElWe are a non-profit organization,staffed by volunteers, 11.0 Health Care 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. I am 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 Policy#or Self-ins.Lic.#1821A Expiration Date:01/01/204 Attach a copy 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi , the a' s and �nalties o perjury that the information provided above is true and correct.Date: I Signature: "`` and /31 n17 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia