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Home My WebLink AboutBLDP&G-20-000270 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK YARMOUTH p, • CITY MA DATE n7/11/2019 PERMIT# g70 JOBSITE ADDRESS 212 MAIN STREET OWNER'S NAME JOHNSON,KAREN G OWNER ADDRESS YARMOUTHPORT TEL 508.362.0170 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED:YES❑ NO 21 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 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 1 OTHER 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 [v7 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 0 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 oomph with all Pertinent provision of the/: 9 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. y✓ n PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 ' SIGNATURE MP Er MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION[f# 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 WORK ORDER 504295$40.00 . p. f�a b r The Commonwealth of Massachusetts , ; ft Department of industrialAccirlents ' E.� f,ra _." Pii 1 Congress Street Suite 100 . _ Boston, MA p2114-20. 7 .► „. www.mass.gav%dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH Mg- AUTHORITY, Ann lira nt'Information Please Print Legibiv. Name (Business/Organization/Individual):E.F. WINSLOW PLUMBING &.HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:,SOUTH YARMOUTH, MA 02664 Phone #:508-394-7778 Are you an employer? Check the appropriate box: 88 Type of project (required) l 0 I am a employer with employees(full and/or part-time}. 7 New 0construction .,E3 I am,a sole proprietor or partnership and have no employees working for me in S. 0 Remodeling anycapacity. [No workers' comp. insurance required.] ID l am a homeowner doing.:atl work myself, [No`workers'comp. insurance required.]`t 9. E] Demolition 10 0 Building addition 4.0 T am a homeowner 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 sole -1 1.0 EIectrical repairs or additions lsroprietots with no employees, 12.a Plumbing repairs or additions 5.0 I am a general contractor and I havehired the sub=contractors listed on the attached sheet. These sub-contractors have employees and have workers' comp. insurance: 13,0 Roof repairs 6.0 we area corporation-arts its officersilave exercised their right of exemption per MOL c. 14,El Other. 152,§1(4),and we have no employees. [No workers' comp. insurance required,] *Any applicant that checks box'Ail 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. ;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, tithe sub-contractors have employees, they must provide their workers'comp.policy number. I am an employer that is providing workers' compensation Insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins:Lie. #:1909A Expiration Date:01/a1/2020 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 11IGI, c. 152, §25A is a criminal violationpunishable by a fine up tot$I,5.00;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 forwardedto.the Office-.of Investigations of the DIA for insurance ;coverage.verification. I do hereby cert� un alitgirl pen hies o perjury that the In arm at onprovided above is true and correct fF .fP l rYf Signature: 4. .•..o a._. . Date: Phone#:508-394-7778 Official use only. Do not write in tins area, to be completed by city or town official City or'Town: Permit/License # issuing Authority(circle one): f 1. Board of Health 2. Building Department 3. City/Town Clerk 4._Electrical Inspector 5.-Plumbing Inspector 6. Other Contact Person: Phone #: