The URL can be used to link to this page

Home My WebLink AboutBLDG-20-000268 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE f PERMIT# 07/09 2019 6-10-0a2&a2.57. JOBSITE ADDRESS 95 CAPTAIN CHASE ROAD OWNER'S NAME SUDBEY GOWNER ADDRESS TEL 508.737.2093 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL PRINT CLEARLY NEW❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED:YES❑ NO APPLIANCES- FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES g NO❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [vj OTHER TYPE INDEMNITY ❑ BOND ❑ 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 ❑ AGENT❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru nd 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 comp nce with all Pertinent provisiop.of the Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MP[[ MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION g# 3281C PARTNERSHIP❑# LLC❑# COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com rx' WORK ORDER 504184 1,1(4 4 �V The Commonwealth-of Massachusetts Al Department of Industrial Accidents keno®• �. �, 1 Congress-Street, Suite 100 ` .r.v: ' Boston, MA 02114-2017 • .tlR9 .1:,.*„.:..... , `► co.' www.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/E1ectr-ic ansflumbers.: TO BE FILED WITH THE PERMITTING AUTHORITY:. Applicant Information Please Print Legibly Name (Business/Organization/Individual): E.F. WINSLOW PLUMBING-& HEATING CO., INC Address, 8 REARDON CIRCLE SOUTH YARMOUTH:, MA 02664 .508-394-7778 G�ty/5tat�IZip. Phone #: Are you an employer? Check the appropriate box: Type.o€project.(required): l. ✓ICI am a employer with 88 employees(full and/or part-time).* 7. p New construction 2°❑ I am a,sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 3,13 I am a'homeowner doing:all work myself. [No workers'comp. insurance required.p -9. ❑ Demolition 10 ❑ Building addition 4.0I am a hbmeovvner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers compensation insurance or are:stile 1 i.[J Electrical repairs or additions proprietors with no employees: 12.❑Plumbing repairs or additions 5.0'I am a general contractor and I have>lured.the sub-contractors listed on the attached Sheet: 13.0Roof repairs These'sub-contractors have employees'and have workers' comp, insurance 6.0 We arc:a corporation-and its.officers;bave ecercised their right of exemption.per MGL c. 14.[pother 152,;§1(4);and we have no employees. (Tlo Workers' comp. insurance required.] I ' Any applicant that checks box#.1 must also fill out the section below showing their workers' compensation policy information.. t Homeowners who submit this affidavit-indicating;they are doing all-work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have. employees. If the sub-contractors have employees, they must provide their workers' comp,policy number. I runt an employer that is providin `wtrkers' compensation insurance for my employees. Below is the policy and Job site information. In s traitee Company ame.ARRO:W MUTUAL INSURANCE COMPANY Polley#or Self-ns. Lic. #:1909A Expiration bate:01/01/2020 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required'under MGL c. 152, §25A is a criminal violation punishable by a fine 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 of up'to $250.00 a day against the,violator. A copy of this statement may be forwarded.to the Office of Investigations.of the DIA for insurance coverage verification. I do hereby certify un pri s t d pen /ties of'perjury that the information provided above is true and correct e Signature: y L. raa Date: Phone#:508-394-7778 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`Departm'ent.3. City/To n Clerk: 4. Electrical.Inspector 5. Plumbing Inspector , 6. Other Contact Person: Phone #: