HomeMy WebLinkAboutBLDG-16-04957 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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5-- - !CITY - 10 __ (_ i� r MA DATE_d.li Cllffi, PERMIT# OZ,-I&croft r 67
JOBSITE ADDRESS 'it f Lrlt c T YI !OWNER'S NAME raja , r. c77---Cci-t--�
G , _ __OWNER ADDRESS —_ ®�TEL r- - 7 /, % FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL[. i EDUCAT NAL_I RESIDENTIAL ,
PRINT
CLEARLY NEW:L_I RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOV)
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER (1—1,------ - { -._ _..—___ r, _l
BOOSTER IT� I- [ 1i— t1 z1 I;_ lit 11 1' I ii !.
CONVERSION BURNER I_ _Ri !_. t' F1 I! _ -_€! €II~--
_COOK STOVE !. I I 4; I, II i I
DIRECT VENT HEATER --- 11_ --1,----- Ti, IL __
DRYER ! _
FIREPLACE _,
FRYOLATOR -
FURNACE
GENERATOR
— _--- ---
GRILLE ;
_._ — — — —
INFRARED HEATER
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LABORATORY COCKS 1
MAKEUP AIR UNIT !_— JI -_ I , '--- _
OVEN i .1., _ I 1 II �t t +1 i !i '
POOL HEATER i - =L I ii _ — —1 II: d1 _ 11- — I I
ROOM I SPACE HEATER I� i: _ J.. _ 'i _I ,i I i_ _ _ I
ROOF TOP UNIT 1._, _
f �jl_ I ?I 1,= ;i _1 I,____ R1,... .._
TEST
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UNIT HEATER __;I I i 'i : _ 'I II
UNVENTED ROOM HEATER I_ I II-- - ! G! `,
WATER HEATER I^—°i I — — I
OTHER Ii:.. -(I_ f,l: i(,. .. li —_ il ii I
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_ N� � z INSURANCE COVERAGE _
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES �J NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [' OTHER TYPE INDEMNITY f` BOND LT
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 D AGENT ,J
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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. // /
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE#L12298 SIGNATURE
MP E, MGF r JP Li JGF L LPG]D CORPORATION J#—3281C__J PARTNERSHIP I#L J LLC Ir_#4 m _
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH z STATE t MA >ZIPL92664 a 1TEL 508-394-7778 1
FAX 508 394.8256 1 CELL[N/A EMAIL accounts able@efwinslow.com — I
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P)(0 — I) ‘.2 tO.0 q (R6 6 e-P4 ,
4_,� Office of Investigations
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F��;� 600 Washington Street
IT ?:1- Boston,MA 02111
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www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): E.C.EA/,br S10v i D[Uv+n61 aVV\cl ` 0.ecL\--,ny ( . 1 viC ,
�t 0 4 )
Address: g' @'�4'c,n C:irrice—
City/State/Zip: ``ja,3-c-V `-r;i,--c,, 1' t'&Pr Phone#: s y - ` q1-1'1?
Are you an employer?Check the appropriate box: Type of project(required):
Ill am a employer with -70 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
;.❑ I am a sole proprietor or partner- listed on the attached sheet. i 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0Electrical repairs or additions
❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13.0 Other
comp.insurance required.]
\ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation.
R (�
isurance Company Name: - ,..t C�,.l hieji 2 4.�S'u,2&,'t(is \ e1N i„'1y
olic #or Self-ins.Lie.#: \ 'A 1 Ac
yExpiration Date: —1 " a o i")
)b Site Address:,. nnr,Ac1v1 vf•ec---1, Au'4', C� �5 'h 4 I �� City/State/Zip: CO Li l�J
.
.ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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 day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
ivestigations h DIA for insurapee7overage verif c tion.
do hereby certify unn e?r le ains ana penalties o pe ju;y that the information provided above is true and correct.
ignatw e: Lk,, / A
l :3 Date: (a i 1 aO t
hone#: .cihg- n` - 7 77
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#: