HomeMy WebLinkAboutBLDG-18-005211 win 4y/ 7 4?3 9161 z401 . -z): 60
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-'°T1 ctt.a' CITY MA DATE .-./..,,,,,,__,,LIZ1 PERMIT# l O/?/Fr-ao /)
JOESITE ADDRESS ' - _ / i,L7 �� 'OWNER'S NAMElvt.� GJ/f�'Qn_^I-
GOWNER ADDRESS,71, ------:ZiaLl.:6ft,i_ Ll TE I _ FAX ,_
TYPE OR OCCUPANCY TYPE COMMERCIAL[-TI EDUCATIONAL L I RESIDENTIAL.
PRINT
CLEARLY NEW:PI RENOVATION:Li REPLACEMENT:0 PLANS SUBMITTED: YESD NOL
APPLIANCES 1. FLOORS--a BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I _.I .....__.-I I` -'I I i`. _II__ :I-.-i M -i ! 'e i .
BOOSTER _.....__G__....._ _._ ._--;_ E� - ----.-
I_�_;l_ _.. 1i---- . I. . .ITi.-- °I_ . -...11..... _'.I. . .f(_� _.I_ -. ;h_ I_--.__ -. _ _'� . ._ 1_ l
CONVERSION BURNER II� .1`-- I-_.-I -, _... .-11--^ I,I_ 1I -.-. _rI_ __rI_� ._ _ '
. _ (- I t I I I f __ i•I -i I [i-"
COOK STOVE 1,-: I I I_ i t i t .I(-
DIRECTVENTHEATER L._.-Ii__-._ �L.__. _'f. . .'1._ _I- :L._.- _ +I-.. .�1...._._. 1.. _ I__.. _lt. _ .[1...._ .f� _11 .
DRYER 1"-_.--Tr - _ 1 ---..- I 7 f_. _ t i -1 _- I q f l i
FIREPLACE I-..._ .;( ;I __ 7!_ `I i _li ._._I:. _ il.. _._IL . .11 ;7 II YI 1
FRYOLATOR I__, . II. I .__;I~..-. .I . l.. �I__i _ YI.--_77L. . .'i..---.T1. L_. -.1r-, 7,[7 1,17
.:.FURNACE I. 11._ ...'I. . .- `I_. . -1I. _il ..- _s7. . I- . .. I. ---1 . . il-..II.-- - 0, .. .fi . .:
GENERATOR i- ----.,I_._...:I_. . I . .- { .. -I:_ 'I. ._ 1 _ . I. . , �I.. --
GRILLE I - „ i ._.... I - ;I. ..�_.._._ _ - . .
INFRARED HEATER I_ I- .. ., E-71. __.=I__ . '1_ 1 . ..,_:L. . ! _:1- L_._ .1. ..._ i .. 'rl_.__
..._
.LABORATORY COCKS __...I--._ 1-_.__'I I _ :I_ i1. i[ ;I _.''I... I- ... .:1 f i -11 .1. __.
MAKEUP AIR UNIT I__i L� I _ E.+I ''77 7
OVEN ..,�E1 11_ ._.;1.-:1:-._jr----11---'I bl. °i- '1, _•�1 .- _i.1 11 _.. ! 'il.
POOL HEATER IT.-_____.
.-- . I,-.:, ---,I
_IIT .1 17.77 `,LTD,.-. h_ iI -'1:7:::`i, , i,._. i1, :. 11 31. -'
ROOM/SPACE HEATER CFI _. _I_....__ill__,.T. I ,.-;I_ ,I� 1._.~:1--_..,-,(1,_,.. 11� :r , ___ _1 _•t 1, 111. ._i
ROOF TOP UNIT L __ -1
f1-_ r . 1--_-.11 .- 1 1,1 —�1-71_ ---,I I 'I.- ._.. ',I. . jI. ,.._[I f.
TEST �._..-.- I__ _,-I_ - -'I `1.- 'I 'i.... . !I. -. - 'I, r-- `L 'I....__,.%1.. _'1- -,tl -.
UNIT HEATER r. _ I . _-i E- !-1 - a l -- ------ _.._- - -
UNVENTED ROOM HEATER (-:;L L.. ._r;l--__i�7— ,I.,---. lI~ . `1:---- I ..,11_ .::1 . 1'I. . .1 . :1 _..._1I7
WATER HEATER [^ _I . . '11 .. 1 .-- -I ~' . li . 'I _.I. +I A. .. .I —_
---= t E- I-___I I__...'1.I - I 1. . -.'[7. 11. 1.1-7 E I - 1;1. . i
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OTHER I. ____I I_._.. i --.. _
—
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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 E
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Lj OTHER TYPE INDEMNITY 0 BOND 0
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 El AGENT El
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 complia e with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE# 12298' SIG AT RE
MP L l MGF Di JP D JGF LJ LPG(I_1 CORPORATION E#-3281C PARTNERSHIP =--# 1 LLC 0#L1
COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE -
CITY SOUTH YARMOUTH - STATE MA i ZIP 02664 'TEL 508-394-7778
FAX 5)8-394.8256 .'CELL NIA ;EMAIL accounts ayp able@efwinsiow.com _ -� � �� s --
Department of industrial Alcc&aenIIs
i {► t Office of Investigations
%,�� 600 Washington Street
•" —1 a. Boston,M4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: lBuiIdevs/ContractolrsfElectricians/Plaa I.I bers
Applicant Information Please Print Legibly •
Name(Business/Organization/Individual): E.'C. vv ✓\S i e,,.t Q(LivkNVIoncl ,2 f4.e.Cr,_ , tr1C,
Address: P.Retr i/1 •
i2 b
City/State/Zip: Soo Phone#: S- 5c1 t-7`7'7 •
Are you an employer?Check the appropriate box: Type of project(required):
am a employer with -7O 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.t ?• ❑Remodeling
ship and have no employees These sub-contractors have $. ❑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
1.❑ I amna homeowner doing all work right of exemption per MGL 11.E 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
tformation. !! " �
tsurance Company Name: ..s �i t tl o-A k rZis(J\r&e'(t2 Car," 'cvvy
olicy#or Self-ins.Lie.#: I I , Expiration Date: —1 — (`�i�
)b Site Address::2. mac;: r~�a✓1 "e Q a lr -e, e Q: 0`)-1 Vi City/State/Zip: C3,)wd 16 7
ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
allure 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
r5f the DIA tvestigations for insurarpeoverage verift ayion.
do hereby certify undep4t a ains ana penalties oft pe/jury that the information provided above is true and correct.
i ature _ _ .-- `^ /� Date: i D-f 3 i a0 t
hone#: °ST)�,'•3`i4 7 7 X
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#: