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Home My WebLink AboutBLDG-18-000449 50 r 1ASSACFHUSETTS UNiIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ° z` CITY O c1�T/�? ,___�...,_. _._.__ $ ..... _ .___ _ _____: MA DATE- Z 7 'PERMIT# �T/8�0 yY? JOBSITE ADDRESS[_3_2__j_if�y LAN _ I OWNER'S NAME Fyn q �"-{ OWNER ADDRESS � ak'T: /N ��i TEI�-"f-y Y „ FAX I �1 TYPE OR � CS7S a�, __ PRINT OCCUPANCY TYPE COMMERCIAL[j EDUCATIONAL El RESIDENTIAL(i CLEARLY NEW:0 RENOVATION:D REPLACEMENT: PLANS SUBMITTED: YESEI NO 1'; APPLIANCES-1 FLOORS-; BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ---�--- t� 1I rI ,1 iI ,I.__.... BOOSTER ---- V i . kl._. .._<!_ Mi I , %L .. I CONVERSION BURNER -' cool<srovE - -. .. i.._._. I__ . . 1-----...€i__._ #r�_.=�1- . �€L.�:.. I�_—.-1 DIRECT VENT HEATER -_ - - 1 f i DRYER 1. _. ,._.I_` ii. . - it l^~ I._.-_..Ij.7-i1-..:_-'`1--._ L_`,ll- _ fl7_.,- _ .t DRFIYER I.� ..-4 I.- --,l� __I Imo- I —_ I r- 'i t i �_1 _1 I. -,3�+ i- . • i it it rI —41 -}= - _- �th:-_= -�i.,. ll_-- i FRYOLATOR L I. W ' _. _ _ _ i..- I L, I FURNACE I ;_____.; . Sys L ----, -I---�_•'_ - h..__ Ir.. ►I.. -�I- -- �:_t�T I — GENERATOR - . - __M .�, . _,_ t _.li,..�II_ . �h --1... . .fh_ _..il_. _ (h-fr'-, GRILLEE I..._ T :I— _, .. _4.1.--I- =-EC.--1'---'-ii.__i_=i.--_jl.. 'I-'I—_' ' INFRARED HEATER 1_._._L_.--"-. a�__..1! 1 (_ - t - i-._. 1 _ • . LABORATORY COCKS • r— [7.7..,---r _ --- -- - : MAKEUP AIR UNIT I i�`_;i` '` _'— ?� 1 .. :(�-_E~ I I^IL POOLOVEN HEATER E 1_ r -I__ ~11_^- _;.__^II -.t i- _ i I—_' - i IT 1 I. . . .! Y I_ _� ROOM/SPACE HEATER i 1 'i. ' ° t'° 11I I I -;I_ -'I^ 1 ROOM!SPIINIT ^rl-- I— I_ �iryl -i1_ -'I FI.-^ i l ll— rl . i,....._ jl.s-._..LI. :! REST 1—.—.I. . _.:I. ... fI. 11-17._NI _.11.. it '_fl rl. 1.. FI UNIT HEATER [- 1=-=-'-;1=_.�-�i__ __ __ !i_ ___.__ -'---'I I _ ,_ I_>.�� 1 UNIT HEAT ROOM HEATER :JET '`1 `1 ! '1 = _11 - __ .I, "fir(-( _ _-_ . . — I 'I fl I _� \ WATER HEATER -,1 1; - :I---a' ''I: _f l fI I I, ' .t 1....- ,iiI �1 OTHER ;I .-11 I� .. I- ' __'I� ii L. . .! _..;1-',i ` . ... .I _ — - ___ --_ _ __.. - i ='i' . .. ��_. - . - I.-.._ it `1.._ ...1 II_:.- I�. h INSURANCE COVERAGE "I have a current liability insurance policy•or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0 I hereby certify that all of the details and Information I have submitted or entered regarding this application are true a 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 a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I STEPHEN A.WINSLOW 1 LICENSE# 12298 SIGNATURE MP El MGFD JPD JGF0 LPGI0 CORPORATION PARTNERSHIP D#� LLCD1 1'# 1 COMPANY NAME:[EF WINSLOW PLUMBING&HEATING I ADDRESS 1_8 REARDON CIRCLE____ _�. 1 CITY SOUTH YARMOUTH STATE MA 1 ZIP 02 64 ___TEL 508-394-7778 ' FAX((508-394 8256 ;CELL N/A— �� Y� �j- - "` t�0_8-39 -82_.�,� ,EMAILI accountspa able@efwinslow.com , Jep�o�rtinent of inolitsirtaL Alcciaems • MI;: 600 Washington Street C-'� c . � Boston,M4 02111 6.Sd www.mass,gov/dioi • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Nu„I tiers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E.,'c .W 1,nS t Qv'.) Qt\hm.to,✓ict f k"t.,,,,-\--= `o J i{lc \.ddress: - hso can C:Erc .f .. City/State/Zip: Sops ivy c 4'v,^cs,., C'kt Phone#: `SOS- (114-11'7CI Are you an employer?Check the appropriate box: Type of project(required): .--11I am a employer with —70 4. ❑ ❑I am a general contractor and I 6. New construction employees(full andlor part-time).* have hired the sub-contractors 7. [Remodeling listed on the attached sheet.t !.n I am a-sole proprietor or partner- These sub-contractors have 8. ❑Demolition working for mee inshipinghve employeesworkers' comp.insurance. 9, L Building addition n any ny capacity. [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.]. officers have exercised their right of exemption per MGL MO Plumbing repairs or additions I.❑ I am a homeowner doing all work g p c.152,§1(4),and we have no 12.❑Roof repairs myself.[No workers' comp. employees. o workers' insurance required.]713.[Other comp.insurance required.] 1ny 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. lontractors 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: (;"61\rTO`.. wad d A- . Expiration Date: t C`�t olicy#or Self-ins.Lic.#: i )b Site Address: ti.meii)�'-0 0 fkki'--4, Ckr\��51`1, t i111 City/State/Zip: C3;�'1 S 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 f up to$250.00 a day against the violator. Be advise,at a copy of this statement may be forwarded to the Office of tvestigations�f the DIA for insurariee overage verif c ion. i do hereby ce`rt fy unde`rst e rains an penalties of(pe jury that the information provided above is true and correct. /inatre _ _ � 4r k D 3 i \ a©�6 hone#: .c'l -'IiH- 7 In 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#: