HomeMy WebLinkAboutBLDG-17-004086 __ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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VI"e (,Ire ._...kv ..`. f ._——_— —x—— MA DATE per- O 7. l7'/'ERMIT# /)/-Pt--/'7-' //SAP
,,OBSITE ADDRESS / D.Peiit-d, , .-1"" 9 OWNER'S NAME 1...�„,_ r-r—
GOWNER ADDRESS ' 0 L 14 TEL<m. -'74./4- FAX1
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Li RESIDENTIAL[✓
PRINT
CLEARLY NEW:[21 RENOVATION:[; REPLACEMENT:X PLANS SUBMITTED: YES El NO[
APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
\ BOILER _ yl_ 'I� I -I: il_ I 1i —I ' i _I I J=I
BOOSTER �- _I_ _ I. L I I .I. i I `I fl 1. l� fl i
CONVERSION BURNER F-.-1 I_. ":1----I - I ~..V`1 V1 I'--cf.-
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COOK STOVE I _ ! -,I�__ I7. I__ II II — } (I.
i 1L....-.(I_y i_ �'I - ITT__. _ . - . �
DIRECT VENT HEATER "L_... 1�
L I. 71r__ 11 I w,1---~II - .. 1� 1--- _.--;, 1�c1 II — t1 I DRYER _ - I. - to i ,
FIREPLACE �I 1,.. kl iI ;l _ 11- 1_ ! ,1 ;I. II I'
FRYOLATOR 1 _ y — 1 1 ;1` I I_. f 1 I r�
t _ iI 'I . E i1 1. }i i '1 --• —
FURNACE _ -- ----- .- --- � __.GENERATOR I ._ •1 I I I i 1 `I 'I i1 Wf'
GRILLE I � I 11--.11; E I I-.. _ i- ,I_ �� i.�
INFRARED HEATER {_ �;I' 'I II __ i = iI ;�� 'I . __.' - 1 ;
'- LABORATORY COCKS 1—:1- 1. - 1- '---.. I' - I. I- _ -
MAKEUPAIRUNIT I il=` I 1 L I l�rl
OVEN EJLtIJL
-'_H 1 -- U1 t 11 II-3 1� I - ,MI F U:i_ M1HEATER,POOP 1 I- I 1 I 'I II_ i
TEST PUNIT - -' .II — -- - _
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"TEST ,i. . .. . - II � I
UNIT HEATER I--_ I- I�.... -III_ FI _,.1 _ , _ __ _ . 1l�® - i __ --- — -
UNVENTED ROOM HEATER �-11 it . —!.La. (F-_ `,I....-li_ 1..- -_:I - 1- �... t _`:tl.,._-
WATER HEATER
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INSURANCE COVERAGE __ ,,s _
I have a current liability insurance policy•or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ri)NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY Li BOND D
;
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 U
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding th s application are true and accurate to the•est of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in corn liance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Ufa a 4.6/„/
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW _ : LICENSE# 12298 -1 SIGNATURE
MP El MGF U' JP[2a JGF[ LPGI D CORPORATION[#L3281 C il PARTNERSHIP[_'!,# -"-.3 LLC L#
COMPANY NAME: EF WINSLOW PLUMBING&_HEATING �I ADDRESS 8 REARDON CIRCLE _� � _1
CITY SOUTH YARN'OUTH 1 STATE FNIA7 ZIP 02664 - ITEL 508 394 7778
FAX 508 394 8256 CELL NIA ;;EMAIL accounts a ab'e a�efwinslow.com _- __ _ __ ,.._ , . _ —
. u21+
_w__ Department of industrial Accraenes
g;• t=:' Office of Investigations
_i:Yl= 600 Washington Street N
=lig• i Boston,MA 02111
--,,z.4' www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information f /� I 1 Please(� PrintLegibly
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Name(Business/Organization/Individual):e.c.W,r\sio� YtVsnY7if, 2,04.0_1-j , `®)let(•
Address: g (40-a l Circle— d
City/State/Zip: Soo kh v-n.. te+ MFr Phone#: `5OI.3a9-1'17Sl •
Are you an employer?Check the appropriate box: Type of project(required):
,, I am a employer with 70 4.0 I am a general contractor and I 6. 0 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 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working forme in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5.0 We are a corporation and its 10.0Electrical repairs or additions
required.] officers have exercised their
i.❑I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
km applicant that checks box Ill 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.
6m an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site 1
formation.isurance Company Name: (ri/�
Y rty,J rk`1ko-j1 /\f el Co_ Cauweckiv--j
olicy#or Self-ins.Lic.#: 12 1 P' Expiration Date: I-1— au-)
)b Site Address:13 r"tars v en hAkt-e•) Cl'd lt.)0 Phil City/State/Zip: 60t4 417
.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 da a ainst the violator.Be advised t a copy of this statement may be forwarded to the Office of
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ivestigations the DIA for insurap overage veil a on. r
do hereby certify u ns an penalties of pe jury that the information provided above is true and correct.
ianatuSe:.-_. IA Date: ('DI 3l)a0t§-
hone#: 512A•354 777X
Official use only.Do not write in this area,to be completed by city.or town official
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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#: