HomeMy WebLinkAboutBLDG-20-003982 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
"t=�� )//4CITY { 07AI MA DATE( 1 1. [j 1PERMIT# N46- o' 7 iritA
JOBSITE ADDRESS (.p(o 1x 4.6 It QA I I I R'S AME J I 11)pp„ 1
GOWNER ADDRESS 3 _kei Okl64„,,,_, .1/e1iti_ r JTEL c203cDk(, ,6 1.-/-6, ,FAX iTYPE OR t=fo7,Jz f
PRINT OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 1 ' RESIDENTIAL RI-
CLEARLY NEW:j-_j RENOVATION:1. _4 REPLACEMENT: PLANS SUBMITTED: YES NO(
APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I
BOOSTER _
CONVERSION BURNER =
COOK STOVE
c---1_, DIRECT VENT HEATER ;
DRYER r
I
FIREPLACE i
00
FRYOLATOR I : 1 I I,
_ FURNACE `, j i
LA GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT i
E_�
OVEN
POOL HEATER
ROOM 1 SPACE HEATER ,
ROOF TOP UNIT
TEST ,
UNIT HEATER
UNVENTED ROOM HEATER
I WATER HEATER
Q OTHER i_ ------ — .
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I i NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ' '; OTHER TYPE INDEMNITY BOND
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 rv— AGENT ,7-
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 accurat to the b st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complianc I a P rtine provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
,__�_____.-----_---.__ .__ I _.___ SIGNATURE
PLUMBER-GASFITTER NAME I STEPHEN WINSLOW LICENSE# 12298
MP{-7: MGF '' JP' JGF—I LPG'r CORPORATION! 1#;3281C ;PARTNERSHIP DC— LLCj#[
COMPANY NAME:!E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE i
CITY ;SOUTH YARMOUTH 1 STATE MA ZIP 102664 1TEL 1508-398-7778
FAX,508 394 8256 I CELL{NIA !EMAIL'INSPECTIONS@EFWINSLOW.COM
2T\ The Commonwealth of Massachusetts
Department of Industrial Accidents
'�4 ' •—r
,, =p _'j? Office of Investigations
.. Lafayette City Center
-" — ' 2 Avenue de Lafayette, Boston,MA 02111-1750
y r www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
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.❑D I am a employer with 90 employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. El 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 10.0 Manufacturing
no employees. [No workers' comp. insurance required]**
4.IIIWe are a non-profit organization, staffed by volunteers, 11.❑Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*My 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#I.
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:
City/State/Zip:
Policy#or Self-ins. Lic. #1909A Expiration Date:01/01/2021
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under§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 cer ' e the ins and penalties of pedury that the information provided above is true and correct.
Signature: /Y -•` /-- ^l..-- 01/02/2020
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(check one):
l f Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board
5.0 Selectmen's Office 6.['Other
Contact Person: Phone#:
www.mass.gov/dia