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HomeMy WebLinkAboutBLDG-18-005433 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t 1 =- '= .""_^ MA DATE �34 1� PERMIT# /°��� F— CITY : 1^' e .' ),.1 JOBSITEADDRESSL L5. J -1 OWNER'S NAME , , ---�---- t GOWNER ADDRESS 17� Cam(}0�� S }� ' . TE i i1 AX ._ .. __ 1 TYRE OR OCCUPANCY TYPE COMMERCIALµ EDUCATIONALRESIDENTIAL[ TEM �� CLEARLY NEW:0 RENOVATION:D REPLACEMENT:] PLANS SUBMITTED;YESO NOD 0 APPLIANCES 1 FLOORS-I esM 1 ©© 4 s 6 7 8 9 10 El��� BOILER ----^1- I�� ��- BOOSTER 1: -�-1-, 1 .7 1.+.�..II-;I,--�.-;I.- :1 7"--1'® CONVERSION BURNER I1. I[:._--'1-- ''I. - .. - 1_- _ •E-_L.7:C_-..-7-. ��� COOK STOVE 1•- '1- :®�rLT[—..- - :1- ..'i �.'C_�-_.�®��a DIRECT VENT HEATER In_...:.,1-� III_ - �IM 1,7 1__w:°II._.'..,II,...-.�-1_*-f ®�I DRYER ET I. .. j 1^-�_,�1�.w._;.. .-1- _-;[_1 :I_ ®� FIREPLACE 1::>'Lµ .�®I...---:1- ----I.----i1 -,r..-_i FRYOLATOR 1-_- I[: +iIf� I�IM._:E."-. P�_ "!I.1 -`I... ..,,�l._, ,��® n MIIIIE FURNACE 1 L, . }��I. ~~ J j :E.T.,I,___®�®®� C GENERATOR _--,i. .__.,'...m_,L. ,r.•. ;I ® ®� GRILLE 1I 'I I-_._ I ' `----.I'. _ . .I. ` :1,` ! ...( 1 INFRARED HEATER L �®I.. I:_-_ 1-T_`I� ,Iw:. 'I . LABORATORY COCKS f�.. :l— I ,... 1 .- 'r7 c-1= .T ®�®® MAKEUP AIR UNIT I--_-.-.i 1 ��I7 f..-.---1 L..,-=..:,-1.:,,,�_-r-T 'L x- IMENINNININIEWA OVEN _®®l.---�Iy !II 1-f 'I '1.._ l®®��® nit POOL HEATER L::11 ®[N!._f. 1.----11 . --:--71:I__ ®� ROOMISPACE HEATER I.. _!1�_�®�I�_`1.= 1 _,. 'I,_f.- 1111111 1.�:.L, - II• '�®� ROOF TOP UNIT 1> :1.17 i�®1.. 'I.,. ..°I. ':II '1.,,_ �I��_= IIM ®� TEST 1 1 � _ �_ -I .._.1=---1�.=:1�� UNIT HEATER L_-._L__-.;®a(.,.., 1 .1... .�_°1.,..�:..1 —II=.:_-®�®� UNVENTED ROOM HEATER ® ®®o �® WATER HEATER _..,w____ .l _ _L's--®MI; _ ..i_ Y-i1'.- 1,~:i. '�® �� �5 OTHER -_.- ®®CT w :j 'I�_ :CL ®®� � '' w'L \-----'r::-1--------------. I:: -a-7 WEINISIMMINIONIMINNIIINIMMINNIIIIMI IS' INSURANCE COVERAGE �"j I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 'I NO „,�`! bQ 11F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW •--4--. • LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY El BOND L 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 0 I 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 agourate 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 1 all Pertinent provision of the . Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � t��, -, 0 PLUMBER GASFITTER NAME STEPHEN A.WINSLOW ''LICENSE ut 12298-: SIGNATURE :�� MP D. MGF0 JP 0 JGF�f LPGI El CORPORATION 'F3281C PARTNERSHIP '14 ; LLCD# COMPANY NAME: EF WINSLOW PLUMBING&HEATING 1 ADDRESS 1,8 REARDON CIRCLE gym;u -� CITY SOUTH YA OUTH 1 STATE 1 JILI ZIP 02664 TEL 1508 394--7778 I/0• ' �_7 FAX 5083948256 CELLNIA �'EMAIL acounispayable@efinslow,com CPS/CPS/ro • , v#-- • • II The Commonwealth of i assachusetts Department of IndustrialAceidents I Congress Street, 5'uiteX00 Boston B �."� oaXr aoz7 Workers' FPWW. sgov/die Compensation Insurance Affidavit:Genera'Businesses. Alican.t.Inforniation TO${, ED WITH THE PE RMITTING AUTHORITY, • Business/Organization 'lease Print Le 'hi ganization Name:E.F.WINSLOW PLUMBING&HEATING CO..INC Address:8 REARDON CIRCLE City/State/Zip;SOUTH YARMOUTH,MA 02664, Phone#;Are you an employer?Check the a 508-394-n78 LEI I am a employer with la______appropriate box: Business Type(required): or part-time). employees(full � 5. �(Retail 2.0 I am a sole proprietor or partnership and have no 6 QResfaurantisar/Eating Establishment employees working for me in any capacity. 7. 0 Office and/or Sales(incl.real estate,auto,etc.) 3.® [No workers'comp.insurance required] 8 We are a corporation and its off[bers have exercisedNon-profit their right of exemption per c.152, 9. ®Entertainment ! no employees.[No workers'comp. rand eq have 10.❑Manufacturing 4.❑ We are a non-profit organization, insurance b volunteers, s- with rnoe employees. g zation,staffed by volunteers, II•®Health Care [No workers comp.insurancereq.] 12.11 Other Any applicant that checks box#1 must also fill out the section below showing *lithe tion should od check have exempted themselves,but the co o their workers'compensation policy information *lit he corporate should check box#I. corporation has other employees,a workers'compensation policy is required and such an am an employer that isprovidingworkers'compensation insurance or my employees Below is the olio information. tsurance Company Name:ARROW MUTUAL INSURANCE COMPANY policy tsurer's Address:23 COMMONWEALTH AVE ity/State/Zip: CHESTNUT HILL,MA 02467 • . I Lucy#or Self ins.Lie.#1821A Each a copy of the workers'come01/01/201 compensation policy decIaxation page(showing Expirationiy numbere and expiration date). I Bum to secure coverage as required under Section 25 Le to$ecure.o and/or one-year )y ar imprisonment, `�of MGL c.152 can lead to the imposition of criminal penalties of a upo o$1,50 a daya p nmen,as well as civil penalties in the form of a STOP WORK ORDER and a fine gIA for insurance covr. Be advised v that a copy of this statement may be forwarded to the Office of usti ations ofthe DIA verification. • b hereby certi , r the ens/ and enaltfes o I • perjury that the information provided above is free and correct nature: �,olr-` , . the#:508-394-7778 Date: t' 1 Jff�cial use only. Do not write in this area to be completed by city or town official ay or Town: ssuutgAuthority(circle one}: Permit/License# Board of Health 2.BuildingDeparfinettt 3,City/Town Clerk 4,Licensing Board 5.Selectmen's Office ontactPerson: