HomeMy WebLinkAboutBLDG-23-9727 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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` ram:. CITY LC _Ya,nciri .- ___ .r_�: MA DATE '.S_-z_3 PERMIT# L : Z 3 7
,-y JOBSITE ADDRESS 1 / `_ noA-A</3�,Py-- ,(____A,_,___ OWNER'S NAME I,AMEX CyA40C'ic.)G OWNER ADDRESS S AII7 t TE(Oe-5-67-07 3-7!FAX I•_
• P OIR OCCUP CY TYPE COMMERCIAL'DD EDUCATIONAL '' RESIDENTIAL''
CLEARLY NEW: RENOVATION:'_ REPLACEMENT:_,` PLANS SUBMI I I ED: YES 0, NO I
APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _z _ )1 ti )1 i —1 ., 1j il y ;' , 't
BOOSTER ;~' } ,._.v. L ..__..
CONVERSION BURNER i '�—'` "r�
COOK STOVE I �' - 1 - 4I 1; — ---
DIRECT VENT HEATER 7-7 _ 1 I ! _ l 7 ----z { 7 •
DRYER ___�' —. 1 t _ _ 'iI- !-..._ . ! l 1- ZI ? t'
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FIREPLACE '._.� _.� _._--
FRYOLATOR i:_ I`._-. a1�_'` __`:I _1 M i jI-si_-�� :� 'i� 1r—s =-
FURNACE -1;----11__ -z� , !- _"; ` li :_.i, •!_ .=.ice ?; .
GENERATOR '___ /! '`._ _ �'_ ?!._. I!_ _.�i ' ti '. -_
GRILLE Ii- - /' I i,j h; li i . I .— { ----1F_
INFRARED HEATER `' ': 1
LABORATORY COCKS . , y .I # _ $ _ i +r.:__- % ;� ! _
MAKEUP AIR UNIT .I �-�, ''__._. �. 'y.__ ' __ ir„_ .'i 1El_v.> -
OVEN __ - I ti I Ii_qI _ 4$_. '
POOL HEATER -___ —` --ir- ` �� i �'� 1Ob2'
ROOM 1 SPACE HEATER _
ROOF TOP UNIT i i'--- ILA °,.w _t' _._ i' ,l - �- _
TEST IL` - j_ 9�_ I ` - 4 f)L[ _�tPAR
UNIT HEATER �_'. r. 'I ` __ -By _ �_�
UNVENTED ROOM HEATER —li� ri -�t. i! I ` 1 __'"_—
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WATER HEATER a '',____ I 2: __ 'I ri---..._ .,; I-- } - I! '
OTHER 1 'i -'- II `i___-'. - - - '' . •_- _ _ � _-_�1 �'! _ _
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INSURANCE COVERAGE •
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES El NO i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ,f OTHER TYPE INDEMNITY 7 BOND L
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachuse eneral Laws,and that my signature on this permit application waives this requirement.
I �J1 1 _ CHECK ONE ONLY: OWNER I E AGENT ri
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are 4 - - . -ccurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn, - 4._it t ro ' ion o0' e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME i .1c: 1-1 n 6,'I _J t'_,� LICENSE#74,y/Cl SIGNATURE
MP 71 MGF JP JGF LPG!Li CORPORATION I #1 t PARTN:;••HIPD.#1 LLC D# - ---
COMPANY NAMEI y1_._ _ a C !- s ADDRESS L1/y_ _Qr.__C ._.5 _ _L=
TEL /v SOR. /`�
•
CITY ���' bo.�6 _,. _. STATE ZIP I/ e)oZ ?-� / a
FAX I CELLS EMAIL ..4.�, n-- -1:).Ccc.L_..Lr. �..�-�.:..�- C..r r_c.,a _ _�_r'�': .
The Commonwealth of Massachusetts
t Department of Industrial Accidents
_..IN= 1 Congress Street,Suite 100
_� 2'y Boston,MA 02114-2017
• www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): 'JO
Address: / / / G t t1 f r •
S`
City/State/Zip: 7)-H/t<' bar-0 t N Phone#: • So,.- 3 /,) - -(///
•
Are you an employer?Check the appropriate boa: Cr;1 7 3 Type of project(required):
1.Q I am a employer with - employees(full and/or part-time).'
7. New construction
2.21 am a sole proprietor or partnership and have no employees working for me in g, ❑Remodeling
• any capacity.[No workers'comp.insurance required.]
3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. El Demolition
10❑Building addition
4.❑1 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 I I.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the subcontractors listed on the attached sheet 13. Roof
These subcontractors have employees and have workers'comp.insurance.: ❑ repairs
P
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[ter
152,11(4),and we have no employees.[No workers'comp.insurance required.] `f
'Any applicant that checks box#1 muss also fill out the section below sbowing 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 snob.
:Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees.if the 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:
•
Policy#or Self-ins.Lic.#: Expiration Date:
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 ' r k pq�ns�r ties o p ju that the information provided above is true
land correct
Signature: •
�I1k�ld/J' Date: /„2/S/r 3
Phone#: 3 ,5 3 I — //(� /
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#: •
Please visit our web site at http://www.mass.gov/dpl/boardslPL
JOHN P HART JR
114 PARKER ST
ATTLEBORO, MA 02703-5025 (PL)
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Fold, Then Detach Along All Perforations
... ......
COMMON
EALTH OF ACHU
DIVISION OF OCCUPATIONAL LICENSU- REBOARD OF
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PLUMBEROAND::GAtFITTERV. ..%:: •
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ISSUES THE:FOLLOWING LICENSE
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JOURNEYMAN PLUMBER ••••!cr '
1g. .i
021.711'fP HART JR -• g
4...14 PARKER
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ATTLEBORO,.MA 0270.3-5025 : d'
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10
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26410 :••••:''.05101/2024 • 257201
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER