HomeMy WebLinkAboutBLDG-20-005750 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
=LI-2` CITY A l�-_ MA DATE qI ill/ a PERMIT# /*1-9-1-,--640- 5 5
JOBSITE ADDRESS 1 P ,t e .S t. 0 r r h Ao% OWNER'S NAME S (c„,
GOWNER ADDRESS 6 15n 51 '5 07.GEC) TELL`gyp)- 43.. 6 5)O =FAX -
TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL I.I RESIDENTIAL
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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 Ft NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ni 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 I ,. AGENT a
SIGNATURE OF OW IEROR.AGENT- w_ __CD
V1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurst—ttYtho b stof•my knowledge----
and that all plumbing work and installations performed under the permit issued for this application will be in compliancnc I a YPprtino provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. it • `/
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PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE
MP(1 MGF® JP D JGF® LPGI® CORPORATION((# 3281C PARTNERSHIP®# J LLC D#
to COMPANY NAME:)E.F.WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP'02664 TEL, ,5( " .r
FAX 508-394-8256 CELLI N/A 'EMAIL INSPECTIONS@EFWINSLOW.COM
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The Commonwealth of Massachusetts
Department oflndustrialAccidents
I' f Office of Investigations
001.4= ;, Lafayette City Center
2 Avenue de Lafayette,Boston,MA 02111-1750
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: E.F.WINSLOW PLUMBING&HEATING CO, INC.
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone At:5508-394-7778
Are you an employer?Check the
appropriate box: Business Type(rev-fir-W. M - —.
.LE2 a .1emplo _ _90 employee`(fulljd/ . 5:-LRetail —
—
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.0 I am a sole proprietor or partnership and have no
ID Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. ❑Non-profit
3.CI. We are a corpora ion and its officers have exercised - 9. Ei Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp.insurance required]"
4.❑ We aie a non-profit organization,staffed by volunteers, 11.❑Health Care
with uo employees. [No workers' comp.insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
"If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
ARROW MUTUAL INSURANCE COMPANY
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.#1909A Expiration Date:01/01/2021
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under§25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up
:o$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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of
he DIA for insurance coverage verification.
do herebycer ' the ins and penalties o
f penury that the information provided above is true and correct:`
i mature: Y "*YV ! 01/02/2020
g Date:
lone#: 508-394-7778
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: l'ermit/License#
Issuing Authority(check one):
L.OBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.OLicensing Board
5.0 Selectmen's Office 6.❑Other
•
'contact Person: Phone#: