HomeMy WebLinkAboutBLDG-18-005479 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY 1__ '' • J MA DATE[(5 3F/1 PERMIT#
JOBSITEADDRESS OWNERS NAMES _,
GOWNER ADDRESS 1 .•r ram; r= nfi1 i R�-., TE _ —
TY1'E OR OCCUPANCY TYPE COMMERCIALD EDUCATIONAL Ej RESIDENTIAL
TRINT
CLEARLY NEW:D RENOVATION:0 REPLACEMENT: PLANS SUBMITTED:YESO NO C"----
APPLIANCES 7• FLOORS--I ell111111311011131 5 6 7 8 9 10 ®U 14 60
BOILER _ ®�I� ®M®® - I i
BOOSTER I ,`I-- t-1®I__ :[.T I. .,i i_721. .�:.,®E
CONVERSION BURNER II�.JiC_- il[ 'T.--- -17 FT3 ---- • rTT3ETE�`I
COOK STOVE ®®�� r�r,.`L
DIRECT VENT HEATER ®� ®��11111111111 n
DRYER ��r I•.: _ 7.1 y,l-_.___.,L. �NN :J
FIREPLACE • I-� I __I.' 'I __i� 1._.. .-<- I-,. '
• FRYOLATOR [- '(r.M I, .-`,(- -_ i"""`A IwJ'= :; M®_ `IE-•7 0
FURNACE L :ETh '.I._ :,I -_--; ;l -.7 `®®_� IMS .�
GENERATOR r -.•Y'.._..--- — • ,..:,1,---- (,- _A!®r"..,~'®I.
GRILLE • I..... .i 1_h,f111111l . :I- ,.. ,. •r ,I.~ ;L. '' `I �I_
INFRARED HEATER �I I r,i��� �®®�®�I' . �®
LABORATORY COCKS I�, ,.I ®1 v ��
MAKEUP AIR UNIT I ,._I�.�__.., IIME7.
111101111
OVEN H
POOL HEATER UMW 1171 L.e
ROOM I SPACE HEATER I,.=...� ®�I.._.—:'I2---�'I-• ® ®®
ROOF 1'OPUNIT I:_..�®�1.+ �1� ,'I.T.T�� ®® I f
TEST _ ®® ® �®®
UNIT HEATER I ._,•�®M®n ®��S C'C '
UNVENTED ROOM HEATER _.i ®®®�NW
WATER HEATER . . ._._..-.....I < _,_®UM1120MNNNNMN S
OTHER � __._._...._..0 MM ® MN®M ®®
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Ea NO L.. 0_,
I if YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
• LIABILITY INSURANCE POLICY +•! OTHER TYPE INDEMNITY J 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 an this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 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 aid 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 compile a with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER GASFITTER NAME[STEPHEN A.WINSLOW _�_-,�-1 LICENSE# 12298^ SIGNAT E
MPL:1 MGFD JP0 JGFL,_I LPGIE CORPORATION D#1`3-281C _ PARTNERSHIP D#,�_`, ; LLC0#
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS j 8 REARDON CIRCLE ____ _-- --T—=
CITY SOUTH YARMOU i H m� __ I STATE b MA_j ZIP-02664 tTEL 508-394 7778„_ _ n
FA 508-394-B256 1 CELL[NIA �EAILLaccounispable@efwfnfowcm M �,
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l The Commonwealth ofMassachuse s
._:,iii.
Department of Industrial.decidents
„" Congress Street,Suite 100
Roston,l 02114 20X7
rev
Workers' www rna.,c you/die.
Compensation Insurance Affidavit:General$usinesses.
A ficaut luformatzon TO BE Firm WPM DIE PERMITTING AUTHORITY. •
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Business/Organization Name:E.F.WINBLO Please Print Le ibl •
W PLUMBING&HEATING CO.,INC
Address:8 REARDON CIRCLE
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City/State/Zip:SOUTH YARMOUTH,MA 02684, Phone#:508-394-7778 •
Are you an empIoyex?Check the a
1,0 I am a employer with ppr opriate box: Business Type(required):
or part-time). employees(full and! 5. Retail
2.0 I am a sole proprietor or partnership and have no 6 QResfaurant sar/Eafing Establishment
employees Working for me in any capacity. 7. 0 Office and/or Sales(incl.real estate,auto,etc.)
3.�] [No workers'comp.insurance required] 8
We are a corporation and its officers have exercised Non profit
their right of exemption per c.152,§1(4), 9. El Entertainment
no ri employees.[Notioper' (),andwehave
4•❑ We armp a non-profites.[Noorganization, insurance required]* I0.[]Manufacturing
ganization s e steer
with no employees.[No workers'co�edbyyoIunteers, II•®Health Care
p.insurance
Other .
�Y applicant that checks box I must also fill out the seuttlo below showing workers'compensation policy'
if the corporate officers have exempted themselves,but the corporation has otherem to
rganization should check box#I. Po cY udormation
employees,a workers'compensation policy is required and such an
am an employer that is providingworgers'compensation insurance or my employees. Below is the olio inform
isurance Company Name,ARROW MUTUAL INSURANCE COMPANY
policyction.
miter's Address:23 COMMONWEALTH AVE
ity/State/Zip; CHESTNUT HILL,MA 02487 .
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)licy#or Selfins.Llc.#1821A
Each a copy of the workers'compensation policy declaration page(showing theExpi policy number1/ expiration
Expiration Date:number
ilure to secure coverage as required under Section 25A up to Icure C 0 and/or one-year A of MGL C.152andi date).
Y ar imprisonment,as can lead to the imposition S tiott of criminal penalties of a
up to o$1,00 dayt, well as civil penalties in the form of a STOP WORK ORDER and a fine
against the io tor. a e verification.
that a copy of this statement may be forwarded to the Office of
u stto$25 s of aha a for insurance coverage advised
that
b hereby cerfi , r the a' I
and enal{ies o perjury thattlie information provided above is true and correct.
nature: ' .
w sue,
me#;508-394-7778 Date: t! � � l`
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lfficial use only. Do not-,rite in this area,to be completed by city or town official
:ity or Town:
sufngAuthoxity(circle one); Permit/License#
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Building ent -
Board ofHeaIth 2.B De .
Other g 3.City/Town Clerk 4.Licensing Board 5.SeIecfinen's Office
ontactPerson:
Pr,..,.4.