HomeMy WebLinkAboutBLDG-18-005040 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .
`+' , • CITY I T • I MA DATEIL2. 111 PERMIT#/* 6-I f CO- 1'I7 U
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JOBSIT ADDRESS G \ j �, c _—Y OWNER'S NAME n• (1,
OWNERADDRESS _ 0 ,�� IEL - C01 FAX _,, ._ _-, Cr-
TYPE OR 1 OG63a j '
PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL® RESIDENTIAL --•t-
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CLEARLY NEW:0 RENOVATION:[1 REPLACEMENT: PLANS SUBMITTED: YESD NOD
APPLIANCES 7- FLOORS--I 85M 11 2 3 _4 5 I 6 7 8 9 10 11 I. 12 13 14
BOILER I-- _1I. (-.-1_ 'I. ..I _ 11_ . . _.kl__ I1 '-1_. _-,;`.1:;,TL_.. —i
BOOSTER i( '(_„ .-I( i Iw. ( `._ 1._..:ir--,-'( �. :I, '�.., 1-11. '1__71.. _'_. .,
CONVERSION BURNER 1 �I E___11(_. ,1- _ ,( ......i.'.__ .,I_ .--, -�'L-< ('I... Q
COOK STOVE I_._ 'i. _`i -__,:1.•M.;i._ -. f __.:L ' '.I��i- '(�_..-.:�----::,.I . 'I.,...,.I..__'°l.,_.
DIRECT VENT HEATER LT]Ir"•`=;�_�:'.:1_.1II,. ..--=1.---..1-, _ _I1, .I•..,.. .C_.-_.,1.�_µ'C_- -,,.L., ,�_:..,_:
DRYER r- i I..... E,.>r. .,.-:,,I ... i._ .1 _ :1-'.�' 1.. ^ :1:: - L,_- µ I:-,...71I. -l
FIREPLACE • I_,_ :(7.-T:. -----i ;I __- '2.i; - I--,1.I_.--7,.:-_-,`I. !,
FRYOLATOR re 7'(..- i 1. -I f"'7 '1.,- •(M - , �-q- _ .,( [--_`I---- (,.„ ,177.
FURNACE ) ( i :1 ,-~-II- '.r- -7.I� w; I :1•.._ I_. : .._c _- 1
GENERATOR I-- ,- -;- ---- -- i, 1 ?I `; 1 i.-- 1--.. '' _:1 .. =;
GRILLE • l Ll I_: I I. [ i 'I. -�.Iw _ —,-_
INFRARED HEATER L- _.1 l< .,.-7,.1 7:I- `I,. I.-.. I `I,,. :. ..i. _._. 'I_,..- 'I__._ L-_._-'I---,,,-,:
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LABORATORY COCKS ET:.:I. ,; 1 -.(** 1_ µr'._1 ; I_ T r. 1 'L .."I. .
MAKEUP AIR UNIT 1`I._.. --. (.:.__ _ -- 1E-:71_ _'h :..- :r: -.`L.:a=I. _-:( _,I1-
OVEN 11 ,1•___..,r -i_I L_ C:7.11 _...-.C - "L,._ I..,_�`I;,!:[w_ iI_.._:i_ -11.-.-1
POOL HEATER I_. _ i r-_-(--_---1-= -1- =- -,f--11-----�------,I .- L,_. ',1.� _i.._7..i L. .-
ROOM ISPACE HEATER (.._.A.1(l'1-.�s (. ;L,-�.'�1.=_-.1___~-(.�-.._ I ..:1.,._.. ill I._ _1 :( ;L .-...•
ROOF TOP UNIT ( !( (_„-.(- 'I—` .Iw. -,� 1 'l`y,:l..�_ .il__1:. •1 _7�.I..., E_... .I:
TEST 1`_1 . .7 - -'1---.1---•.;- r-----( ---,F.-.1 -• .;1 ;t_ i
UNIT HEATER ' 1-. ,E. I_--.`1. . (- -�1.. :L.7::1. _'r (.:-,- 1-_.:.J-I---- 1-^'I - ~ .
UNVENTED ROOM HEATER E.71I_1_-_~E C. , ',I. I-_ (.`'1. :-_.�'L_....._1__.. 'C-. 1 ,_ � `(~ ,,
WATER HEATER ..., . L .Y-l.r -I 7'(;--.I_.-,I .. ';--.-i(,^,:.1. !i.__M-,L... .F:. ..:1 1 M.:I�_.:_.
OTHER.., -- -- 1 - 11_._-1[1 Ll 'j im7a---:I_7I( L._..zilr: _7L_�_ �L.�_:7_�l.-�.�I[=-_i'1_ e
f -�--_---- _r -.L_.. :;.._..1 I-____;I7`�- i 1_-_1.0 :_�- I:....._,.I_ �.'L--__ .__ ;i ` " :C- �_'i 'Lr��L�IE'E'
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO Et
I IF YOU CHECKED YES,PLEPrSE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
• LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY fl BOND 0
. OWNER'S INSURANCE WAIVER:lam 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 Di 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 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 corn nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i,44,e-bz4-/
PLUMBER GASFITTER NAME STEPHEN A.WINSLOW _j LICENSE# 12298 i SI NATURE
MPD MGFL JPC JGF TJ LPG]El CORPORATION 0#F3281C PARTNERSHIP JJ#1, 1 LLC0#
COMPANY NAME: EF WINSLOW PLUMBING&HEATING 'ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH ..,T, .__.._____.,.---,,.. STATE _ ZIP-02664 QT778 TEL 508-39.
FAX 508 394 8256 CELLINIA �a- EMAIL accounfspayable@efwinsfowMcom �� ____� 1
A
The Commonwealth o f afassach asetts
''MI Department of lndustrialAccidents
il<I ► 1 -
�; '4Cgngress,5'tyeet,Suite 100
Boston,MA 02114-2017
"�� www.mawgov/dia
ov/dia 1
Workers'compensation Insurance Affidavit:General Businesses.
TO BEFREDWITH TRE PERMITTING •
A lica>rtTnformation
Please Print Ile ibi
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:
1.❑✓ I am a employer with 1Business Type(required):
or part-time).* ---employees(full and/ 5• Retail
2.0 I am a sole proprietor or partnership and have 6 ❑RestauxantBar/Eating Establishment
employees working for me in no
any capacity. 7. ❑Office and/or Sales(incl,real estate,auto,etc.)
[No workers'comp.insurance required]
3.® We are a corporation and its officers have exercised $ Non-profit `
9. ®Entertainment
Kur
their right of exemption per c.152
no employees.[No workers'comp.insurance
and we have 10 El Manufacturing
**
4.[ We are a non-profit organization surance orequired]
with no employees.[No workers'comp.insurance req.] 12.0 Other
orgat*Any applicant that checks box#1 must also fill out the section below showing Their workers'compensation policy information. •
he 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.
Taman employer that is providingworkers'compensation insurance or my employees. .below is the policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insnrer's Address:23 COMMONWEALTH AVE
City/State/Zip: CHESTNUT HILL,MA 02467
Policy#or Seli ins.Lic.#1821 AExpiration il,
,
Attach a copy of the workers'compensation policy declaration page(showing the pol yDate:number0and 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. 13e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I
T do hereby certi r the crime and amitL
e7 jury tliatthe information provided above is true and correct.
tY/
Si afore la --<.
r // -
lal Date use only. Do not write in this area,to be completed by city or town official •
City or Tom:
AuthorityPermit/License#
Issuing (circle one):
1.Board of Health 2.Building Department 3.City/'Tovm Clerk 4.Licensing Board 5.Selectmen's Office
f.Other
Contact Person:
Phone#:
www.mass.gov/dia