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Home My WebLink AboutBLDG-19-000413 I. I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK , , k t ►; •' CITY YARMOUTH MA DATE 07/16/7(118 PERMIT#f Per/y—Ulo ill, JOBSITE ADDRESS 86 CAPT CHASE ROAD, S YARMOUTH OWNER'S NAME ROCHA, DAVID GOWNER ADDRESS TEL 774-644-2420 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[v]' PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:V PLANS SUBMITTED: YES❑ NO 0 APPLIANCES-1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER 1 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 [V' NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑1 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 true ?d 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 compli ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ , t-, ry> ,.,./ PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE# 12298 SIGNATURE MP[g MGF❑ JP❑ JGF❑ LPG! ❑ CORPORATION [21# 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 accountspayableRefwinslow.com W10 477373 $50.00 51 6. 1 t Department of industrial 4cctaents t•-an-,a] -Eft Office of Investigations t ar 600 Washington Street Ate • _ Boston,MA 02111 �-u www.mass.gov/dia ' Workers'Compensation Insurance Affidavit: /�Builders/Contractors/Electricians/PlumbersPrint Lei 7 Please Applicant Information ` ' Name(Business/Organizaties/Individual):e.c•WIrS. Ov.I Y(Vw.bi.('2s .Al`to_\✓i, `a ,ielC.. Address: Keo& CIrr.�.e- . a City/State/Zip: SaAh w-'o,�1es NPr Phone#: `Oki-3`+4,-17/'1 Are you an employer?Check the appropriate box: Type of project(required): ,,r1 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 Remodeling :.0 I a sole proprietor partner- listed on the attached sheet.t7 g shipip and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5.0 We area corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.0 Plumbing repairs or additions 1.❑I ys la.[No workers're doing all work � §1(4),and we have no 12.0 Roof repairs myself.e r e .] comp. employees.[No workers' insurance required.] 13.0 Other comp.insurance required.] thy applicant that checks box NI 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 formation. (� /� ("*Jj0.A1 ( PtNG1.11C.2 \ f'lN`�V1`1 tsurance Company Name: (rIY YO•� . olicy#or Self-ins.Lic.it: ]' a) A • Expiration Date: 1—[" aOl`) rb Site Address: 3 GYin n v''e e-1 )C1' MI City/State/Zip: Da W b 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 sue 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 Eup to$250.00 a da a ainst the violator.Be advised t a copy of this statement maybe forwarded to the Office of ivestigations the DIA for insurart overage veri a on. r do hereby certify un e ;Zs a penalties of p jug that the information provideA above Is true and correct, 4 rn Date: 1' .13t aflk hone#: .S11R•'A5"1-777t; • 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#: