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HomeMy WebLinkAboutBLDG-18-005359 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK . CITY � r i MA DATE _ __ T/1PERMIT#/°11,n�?'`$-G� • JOBSITEADDRESS S y1WZOGi EP-I OWNER'S NAME _____ -S GOWNER ADDRESS Z T`V S/ qci _. .... 1 TEL 'Z f5IFAX ;�._,�a.='] TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL® RESIDENTIAL PRMIT CLEARLY NEW:D RENOVATION:El REPLACEMENT:Vie PLANS SUBMITTED: YESO NOD APPLIANCES 1 FLOORS-} BSM 1 2 © 4 5 6 7 8 9 10 11 I. 12 gm 1414 BOILER 11_--_ •i. ;®®IT-7 1 I' "I° 7-_-.'®_ �M®I�® IMINM BOOSTER ®®M[.- il. _.I c T _'I._:17.I,._ 'L ®® CONVERSION BURNER 117. _I[,___ I ;(� - .1- "1��177 ff.' tl-. .1 COOK STOVE (-J_ i_`- ,r_. ;11 In t-1® � niNle DIRECT VENT HEATER I�. :_�:I�Y ; �I,. .,L.- M ��� DRYER ��...'®�®h_-_.•_L._- `� ®� � FIREPLACE . 1.�,..._®®�®�I�w®�� FURNA TEOR I ii '• ®�®®���� MINWINIMIIMIEWE FURNACE � ��®®�®_....._; GENERATOR I 1:-.- -; I,_ _ :I, _���®�� GRILLE • IS z:1 j--"i I®Il i 1.: "1,_.r. W® INFRARED HEATER L-[_1���®®®lm®®®i � LABORATORY COCKS �:1— . II-.. i__ i _ . .-_,1. _ 1—`1- MAKEUP AiR UNIT ( .i(r.. L_..rt 1 I. W j.®®®®®® ____���� OVEN L,.__.z®NE I. . _ I��� POOL HEATER L-F®® _ __ '. . aill-. Mir %) ROOM I SPACE HEATER 11110311111111110i._,1-,E _-'I.-. I.I:� __ I ;®wed®� xi ROOF 1'OPUNIT �_®��.. 'I,, ..,I�..�_` TEST 14 ®�®��i®®1.. ®���� UNIT HEATER __'�®�®®��®�IIIINNIM®®� UNVENTED ROOM HEATER L. ® ;. ®�� WATER HEATER .11 `® ® .--yi � ®®®® OTHER I ®� ® ®�®® ®l.r_.,-._�I., ,II�._111IN rr --.� �. - - -tiInfinemenoteniumimalimmoveniossio INSURANCE COVERAGE S I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L 'I NO L On i IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW . LIABILITY INSURANCE POLICY£ OTHER TYPE INDEMNITY 0 BOND E. OWNER'S INSURANCE WAIVER:lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the -14 Massachusetts General Laws,and that my signature on this permit application waives this requirement. O. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certlfythat all of the details and Information I have submitted or entered regarding this application are true accurate to the best of my know edge and that all plumbing work and installations performed under the permit Issued for this application will be In compli a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAMELSTEPHEN A.WINSLOW I LICENSE VW] SIGN URE MP El MGFO JP 1 JGF:I LPG]J CORPORATION(f i#13281 C 1 PARTNERSHIP D#L.�.y. ,,,._., LLC ;#t COMPANY NAME: EF WINSLOW PLUMBING&HEATING I ADDRESS 1.8 REARDON CiRCLE _ _._——__-- CITY SOUTH YARMOU T H____ w.. T 1 STATE ELAILki ZIP IL2p1 µ �jTEL 508-394-7778 __ //�� � i f FAX 508 394 8256 1 CELL NIA_____ EMAIL aountspayable@efwinsfow.com � � ,�__ �_ - i • I The Commonwealth of Massachusetts Department ofInd trialAccidents II 1 Congress Street,Suite 100 - ,` Roston,MA 02114 2017 WWW.maFsgov/dia Workers BE compensation TO$� p n Insurance Affidavit:Qeneral businesses. Ap lit'antlnforination MAD WITH THE PERMITTING AUTHORITY. • Business/Organization Name:E. F. Please Pint Y eribl- WNSLOWPLUMBING&HEATING CO,,INC Address:8 REARDON CIRCLE • City/State/Zip;SOUTH YARMOUTH,MA 02864. Phone#:508-394 7778 Are you an employer?Check the appropriate b ox: 1.d I am a employer with 1 Business Type(required): employees(full and/ 5• Retail or part-time). 2. I am a sole proprietor or partnp and have ershi 6. C1RestaurantBar/EatingEstablishment no [No workers'comp.' 'capacity. 1• Q Office and/or Sales(incl.real estate,auto,etc.) employees working for me in 3.® We are a o p in any required 8' corporation and its officers have exercisedNon-profit their right of exemption per c•152,§1(4),and 9. 0Bnfertainm.ent we have 1 r no employees.[No workers'comp.insurance required 10[]Manufacturing 4.❑ We are a non-profit organization,staffed b volunteers with no employees. Y 11.0 Health Care [No workers'comp.insurance req.] Any applicant that checks box#1 must also fill out the section below showing 12.®Other *Any corporate officers have exempted themselves,but the heir workers'compensation policy information. organization should check box#l, corporation has other employees,a workers'compensation policy is required and such an I am an employer Mat is providingworkers'compensationCompany insurance for my employees Below is the policy information. Name: MUTUAL INSURANCE COMPANY Iusnrer'sAddress:23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL,MA 02467 • Policy#or Self-ins.Lk.#1821A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Expiration Date:01/01/201 F' • Failure to secure coverage as requiredxp n qua up to secure and/or one-year under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a :f up to o$1,00 a 0 aY imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine y againstsu violator. Be advised v fithat a copy of this statement may be forwarded to the Office of nvestio$25 s 0 they a for insurance the vnce coverage verification, do hereby cerfi I r the airs and enalties o perjury that d1e i forYarrtion provided above is free and correct. • 'i nature: 4 . .F^'r�Gam,.,.. hone#:508 394 7778 bate: 1 � , Official use only. Do not write in this area,to be completed by city or town official City or Town: rssuingAnthority(circle one): Permit/License# Board 6,Other of Health 2.Building Department 3.City/Town Clerk 4.LicensingBoard 5 Se. Iectmen's Office Contact Person: Phone#: