Loading...
HomeMy WebLinkAboutBLDG-26-267 _4J, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • CITY: Yik.41 GC/ MA. DATE 4'' ale'. PERMIT# �G—Z1P 2(7 JOBSITE ADDRESS: 2-76 /77`6 4 fro-kf /OWNER'S NAME: C Ad.4-GC/�() GOWNER ADDRESS: TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIALL— PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:Q-- PLANS SUBMITTED:YES❑ NOrg---- APPLIANCEST FLOOR-' Bsmt 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 VI INFRARED HEATER Gu LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER J ROOF TOP UNIT TEST / UNIT HEATER r.yl UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch,142 YES NO❑ K you have checked,please Indicate the type of coverage bychecking the appropriate box below. LIABILITY INSURANCE POLICY Lys OTHER TYPE INDEMNITY 0 BOND 0 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 0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit Issued for lids application wit comp nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /j7f7.ee PLUMBER/GASFITTER NAME:fr 1C4,1.4/4/, ..?TGLr Q.4 LICENSE# 1/?rfr SIGNATURE COMPANY NAME: /144714i /f/I ADDRESS:7 PL/i2-f,�// C,41. CITY:/T CLx/GZ/ STATE:/114 ZIP:O'-G lJ FAX: TEL: 5-472-3J,-,7-5-5-7 CELL: EMAIL:/39/ T7—1 7;°,S!/,1- 4Z,77 MASTER JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# EfM ADM&S:. . The Commonwealth of Massachusetts =w ►—i, Department of Industrial Accidents a ==,11 1 Congress Street, Suite 100 �y r c?�1. Boston, MA 02114-2017 r =� www mass.gov/dia .. Workers'Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers, TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): /i42 7y41-- , V/ Address: "7 /L 14-S/ / /2444 c-/X., City/State/Zip: / 4,4Gz-lC# Phone#: .i ()7 2 3 7 2 S S'7 Are you an employer?Check the appropriate box: Type of project(required): l.❑I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.EtriE.a sole proprietor or partnership and have no employees working for me in $_ ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. 0 Demolition 10 0 Building addition 4.❑I 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 11.0 Electrical repairs or additions proprietors with no employees. 12.ePrunbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 Other 6.0 We are a corporation and its officers have exercised their right of exemption per MGL.c. 14.0 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information t 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. lithe 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: F, l4.44 P/M4/L y Policy#or Self-ins.Lic.#: .2-00/ X©G G'G. Expiration Date: '/-3 -2-7 Job Site Address: 77(s A7` CI 4i 4fnt S% City/State/Zip: V irt/-1 ZZ 7// 't/l 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 arid 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 u der the pains and penalties of perjury that the information provided above is true and correct Signature: X46d.; Date: 4/62.-Y '.7- Phone#: S 7 T 2-3 2 a`-S'S7 Official use only. Do not write in this area,to be completed by city or town official , City or Town: Permit/License# r• Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person; Phone#: 1{