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Home My WebLink AboutBLDG-26-185 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK II CITY: 4/1 /^r/D MA. DATE: a/C 2 6 PERMIT# r—Z40 JOBSITE ADDRESS: 17-9Ll2� /7' /icy/4/WNER'S NAME:/ /O/)7_.iJ r /(_ j i# G OWNER ADDRESS: lSl 5 TEL:,/27-5-3&',1AX: TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:it PLANS SUBMITTED:YES❑ NO or APPLIANCES? FLOOR-, Burnt 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 GENEGRILLE RECEIVED.. RECEIVE D V1 INFRARED HEATER W LABORATORY COCK MAKEUP AIR UNIT rI 40iU OVEN POOL HEATER giw INr:nFr,grr✓.,•rar ROOM I SPACE HEATER J ROOF TOP UNIT TEST UNIT HEATER 14.1 UNVENTED ROOM HEATER WATER HEATER 2 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES❑NO❑ If you have checked lIna,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY[[. 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❑ AGENT❑ 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 this application will be In compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chap r 142 of the General Laws. L, PLUMBERJGASFITTER NAME: �G 8 Co!J(O P LICENSE#//q v77 , SIGNATURE COMPANY NAM �� rl O f` ✓ ADDRESS: 37 f7'q/Wi/1) i' t- " CITY: `' Y`7 n l'// S STAT ZIP: r%zljD/ FAX: TEL:7) /17, .7U CELL: EMAIL: / • Oh MASTER❑ JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑#/DM LLC❑# c jry/lic ADDrZc--SS: ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes Ho THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 1 ne e,ummunweuun uj lrlussacnuseus Department of Industrial Accidents Office of Investigations ,= Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /,, �J Please Print Legibly Name (Business/Organization/Individual): /(G'i P M'/"6 c3 (/ Address: 3 �' �`-�� L•- /., cr .� �I S City/State/Zip: Phone #: . Are you an employer? Check the appropriate box: Type of project(required): 1.0 I ain a employer with 4. El I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.[T I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. []Demolition workingfor me in anycapacity. employees and have workers' P tY z 9. [] Building addition [No workers' comp. insurance comp. insurance. required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. r 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 nnployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. r am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site nformation. nsurance Company Name: 'olicy# or Self-ins. Lic. #: Expiration Date: ob Site Address: City/State/Zip: ,ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided ab e is tru and correct. mature: Date: "3 Z 5— Z O lone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority (check one): 10Board of Health 20Building Department 31:City/Town Clerk 4.0Electrical Inspector 5Elumbing Inspector 6.0Other iniormauoii "Julia Li IA�.,�vu� Massachusetts General Laws chapter 152 requires all employers to ers to rovide workers' compensation for their employees. � the service of another under any contract of hire, Pursuant to this statute, an employee is defined as "...every person express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any twoor�more engaged in a enterprise, and including the legal representatives of a deceased employer,of the foregoingjointto employees. the receiver or trustee of an individual, partnership, association or other legal entity, employing emp occu ant However the the owner of a dwelling house having not more than three apartments and who resides therein, or on such dwelling house dwelling house of another who employs persons to do maintenance, construction or ai be deemed to be an employer." r work or on the grounds or building appurtenant thereto shall not because of such employment MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has notproducedacceptable table evidence of compliance with the insurance coverage required." P 7 "Neither the commonwealth nor any of its political subdivisions shall Additionally, MGL chapter 152, §25C( ) states enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance�� requirements of this chapter have been presented to the contracting authority. Applicants Please fill out the workers' compensation ensation affidavit completely, by checking the boxes that apply to your situation and, if -contractors name(s), address(es) and phone number(s) along with their certificate(s) of necessary, supply sub-contractor(s) with no employees other than the insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) does have or partners, are not required to carry workers' compensation insurance. If an LLC or LLP members policy is required. Be advised that this affidavit may be submitted to the Department of Industrialould employees, a p y Q The affidavit should Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Department nt of p to the cityor town that the application for the permit or license is being requested, not the e be returned Should you have any questions regarding the law or if you are required to obtain a workers' Industrial Accidents. compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for yo u to fill out in the event the Office of Investigations has to contact you regarding the applicant.the ermit/license number which will be used as a reference number. In addition, an applicant Please be sure to fill in p permit/license applications in any given year, need only submit one affidavit indicating current that must submit multiple (cityor necessary) and under "Job Site Address" the applicant should write "all locations in policy information (if ne ary) town)." A copy of the affid avit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog or permit ermit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations ns would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of MassachuSetts Department of Industrial Accidents Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE Fax (617) 727-7749