HomeMy WebLinkAboutBLDG-17-006587 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
sry �tl'c> CITY ._,.. ._._ _......... _ : MA DATEJ5'-/ I PERMIT# -/)(7 l -(/b 05
JOBSITE ADDRESS ' I f �y {OWNER'S NAME /I'if /1 j/7 f 0 S f C /�� 1
► G OWNER ADDRESS ihodc. Vi17JL TEL 1 - /Qj FAX1 1
TYPE OR
Y PST OCCUPANCY TYPE COMMERCIAL[- EDUCATIONAL D RESIDENTIAL Eaz
CLEARLY NEvN:__I RENOVATION:D REPLACEMENT: PLANS SUBMITTED: YESD NOS
APPLIANCES Z FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I,__.—:L. ._. .. I . :I '? I !i_ ;i i14 11.. �! i 4-7_i ��� i
BOOSTER ... i ..._ r.�.- % _..-._il II T t fl . ._ii IrY..,.-Il I.
—I_ I I. 1 1 . I __ ,Ii. _
CONVERSION BURNER I,TtI iI 1 -. _ 117. l l t-.,.__II.�.TI_ it ii 1 -I(�W
\ COOK STOVE I _ ,I 'I II
il. ll� !I ,I � II . .II 114."+`
DIRECT VENT HEATER 1 .I L..___-'j l; — _—_�,.. _._ I
_`�'— i i1177 I 11. I: -i I �I I }��-y-Ti E___
DRYER I I • ---I _ __IL. ..I ._ (_._ II ;I. ....1, _ ... i }I .., 4.__ 1
PIREPI ACE I I. -.T. I. I 'I__.. t '` I I- 1 - ,- lI jl
FRYOLATOR II j 1 ;I ;r,- fly _ ;1. _. 4'1. .7i I .-_ 1~rn +I 1 II -1IiC7-'
FURNACE I I Imo. II f n i ;, _.c 7I_ 1---;1— 'i 1 -ti I
GENERATOR • I._... ..I_._ . ....:I_ . I. _ :1 i: It...__ 11 _
..:1. . . . . ,1_ i1 '1. ...
GRILLE I__ .1 II t' 1 11...._ I1 1_=. �I_ _. I�_e_ 1 I�_..-ii - !
INFRARED HEATER 1_ . 1 1 `1� L.... I `l `I :I ,I 71 ..1:1 ,i ,t
LABORATORY COCKS _- - 7 .il I ' _ _ :
�. MAKEUP AIR UNIT I_ I I_. _-`I _. 1— t . a r l' - II i 1_. . I._ ._ I �l j 1, I I.
l` OVEN l._-1— f1 II `1 =-:(1_---_—th_t' bl —ii_ 1—_ ��---rl it 1_ I_, ..'7
,POOL HEATER 1_7_.1 .,11 I `I I . ' ;) lid 'I -- II 'I i1 III_ tI --!
_I_ €I . _ 1__..;I `I~ I- (f 4i� ?1m11 (( 1 _ l
ROOM 1 SPACE HEATER _11771... _
j ROOF TOP UNIT I�_—I I 'I1 1 I�- i. ._ I it 1 'I. ti_ I I_�-1 41 - kl
- --
)TEST I �i.. . . 1 `4._ I .11 ,"I '1 l _ `1, _ I � !
i
UNIT HEATER 1.--,-. —._ 1 11 1� 'I
UNVENTED ROOM HEATER I i I t I _`I—�_.-i[--L._Ij 7 L.. _:I _'1_._ r LI?Is - '
WATER HEATER {' 111 11 '1 I��i `I ~. ;I. 5; i..y_ .d 1 i ,I
OTHER 11� i l _'I_ f `�.I 1 I ;I 1_ '17 I ' 'I _ I i(- 41. i
— _— - - 'I 1 `I tl 1 .. ----__)i. _.._ 1 -- I I I _ 1 '1. _ 1
1 ._ _ ___.._._.�. I I _,..1 l iE { . { _ e I 1 -
If �1— I
INSURANCE COVERAGE
I have a current liabilil insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO D
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Li OTHER TYPE INDEMNITY El 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 D
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•est of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in complia a with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE#L12298 eSIGNATURE
MP[7:1 MGF Di JP„... JGF El LPG]D CORPORATION LT L3281C -_Il PARTNERSHIP Ell=LLC pi#
COMPANY NAME:EEI:WINSLOW PLUMBING&HEATING _��I ADDRESS 8 REARDON CIRCLE _
STATE MA� ZIP 02664 ITEL 508-394-7778
CITY I SOUTH YARMOUTH --9-
FAX�508-394-8256 CELL NIA s I:EMAILI accounts affable efwinslow.com T. _ -_ . _ _ _._ .. ._._ _____
1
o_lcinl :� Office of Investigations
_„�� 4� 600 Washington Street
r=�,,F Boston,h�021I1
.","--`" www.nwssgov/die
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Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information
t� ` Please Print Lerribly
same(Business/Organizationindividuat):E,C.Wt,�$• iow Qs o. ovs a.(�{0.t'r•
/� /} Cam- I elf,
Address: .. t podtrct CUC.tQ.. }
pity/State/Zip: o kvr `ftrd,,,c,,,k-s Fkik Phone#: 505-399-1?7SI
re you an employer?Check the appropriate box:
4-1am a employer with '70 4.0 I am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
❑I am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'comp.insurance.
[No workers'comp.insurance 5. 0 We area corporation and its 9. ID Building addition
required.] officers have exercised their 10.0 Electrical repairs or additions
0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.]
13.0 Other -a
ny applicant that checks box NI must also fill out the section below showing their workers'compensation policy information.
lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ostracism that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
tm an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site
formation. ((��
aurnuce Company Name: t 1(YD •y ("t.1h'0.l ). ,,tom Co w
s-I
dlicy#orSelf-ins.Lich.^#: 1' .I A ` Expiration Date: t—I- ac�r7
b Site Address:a23 Cctncamova v.-0u Al}5 �y Cl dij . (-n 11 City/State/Zip: D,W(;)?
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
ilure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
se 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
'up to$250.00 a da a:ainst the violator. Be advised tjlat a copy of this statement may be forwarded to the Office of
vestigations, the DIA for insurap overage ven,,a on.
/
to hereby certify un a airs an penalties of p•jury that the information provided above is true and correct
gnatur Date: (a)3 i I Rolf
cone#: St1k•35H-777g
Official use only.Do not write in this area,to be completed by city,or town official.
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City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of I3ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Persona: Phone#: