HomeMy WebLinkAboutSprinkler permit - Sprinkler Permit - 1011 OSGOOD STREET 4/17/2012 C7zz
+ APPLICATION FOR PERMIT
C1t or `own Date V7 DIG SAFE NUMBER
I -L—
V V art Date:
In accordance with the previsions of M.G.L. Chi ter 148k as provided In Section application is hereby made
t-
by 4T'C>'o—1 V'��':-n 0 t'�
(Full name et erson,-Firm orCorp ra�r'in)
i
Address .
For permission to (state clearly purpose for hick permit i requested)• �-�� ���. �E y_.1 _ ��
( Q -t5q�.op ef�_iLtQCz, r-nea� 'o6--
Iaeof competent operator If Applicable) � � e . No.
Date Issued-rejected
Date of expiration Fee id Due
, - .
IP
:P6(rev.3100) 02 5, ol, C 0 72AY5 +
4 PERMIT
f r
• � [DIG SAFE NUMBER
Date i l
+ Start date'
Permit Number (if applicable)
_ _.. • i +
In accordance it the provisions f M.G.L. Chapter 148, as provided in this permit Is granted
to Ft PQJr6_ i
" (Full nacre o/person,Firm or Corporadort)
6co
-
o
stri ti ns.
at
die location by sfreel and no.,of describe In such manner s to provide adequate idenlilroafioe el location) .
This Permit will expire on
� e Paid _. +
Signature of, ffi ial Granting Permit
The
Commonivealfli o Ma sac
,� sets
Department OfIn dustrial Accidents
Office Of Investigations
boo Washington Street -
ostn,MA 02
' 1 . a S-gov1d
Workers' Compensation Insurance . ' davi .� itrs C ra or l tr i i
s Pl x�Applicant Information
Please Print a iI
Name (Business/organization/Individual): zt _e .�V 4r
,
. Address:
City/state/zip:
P
hone fl,, , 10
Are �an employe r? the �-
the appropriate box�- p 'prat(required):
1� 4 plarn a employer with . El I a general contractor and
Ne
employees(full and/or part-time).* hair sub-contractors hired the u � v �r t� t�
2.0 1 am a sole proprietor orpartner- listed on the attached stet. 7. Remodeling `
slip and have no employees These sub-contractors have Demolition
working for me in any capacity. workers' comp# insurance.
[No workers" comp. insr . �e � �x� d�� addition
once re a corporation and its
required:] officers have exercised their � ,1:1 Electrical repairs or d�ti
ors
.El I am a homeowner doing all work right of exemption er M l 1
��. .El Plumbing rear or adlti
ores
self. [No workers'ers' comp. , §1(4), and we have no
1 2. hoof repairs
insurance required.] t employees, [No workers'
comp. insurancer 1 1:1 Other
� required.]
*Any applicant that checks box#I must also fi1I out the section below showing their workers'corn ensation policy info ff��}'atioi/�
r
Homeowners who submit this affidavit indicating ti they are doing a]I work and then hire outside contractors �
untrator that check this box must attached an aditicr�al sheet sito �n the name of � t sttb �� new affidavit indicating such.
sub-contractors and their workers'ooP,poIieY information.
-airy an employer that rsprovNin workers insrrraaor rrerp�ayees. ea is
policy
afo i
rrf �r�ra� �o�t.
Insurance Company Marne:
Policy 4 or Self-in Lie, 44,00,s. ,
- Expiration Tate.
Job Site Address - City/Stale/Zip:
Attach a copy of the workers' compensation policy declaration pacF sho
1ving the policy number and expiration r
Failure to-sec re coverage as required under Section 25A of MOL e. 1 can lead to the imposition o criminal e
p penalties of a
-dine to , .0 0 and/orone-year imprisonment# as well as c i A I penalties ire the form of a STOP 'FORK ORDER.and a fire
o f up to$2 5 0.oc a day against the violator. B a advised that a copy of this statement mar be for carded to the Office of
Investigations of the DIA for insurance coverage verification,
rho hereby certify wi der th e p a h z s ait dp enailperjury that the hi r�iada :provided above is true and correct
i nature. r ���-�"'# ��� �� ��-.� 7 date,
Phone :
7cial rr only. o n write irr his area, to orrrple ed by city r town official
0 Town: Permit/ Ae nse ft
Issuing Authority "3V
,.1. Board f k ealtl . uildin epartmen-t . Clty "I own Clerk 4. Electrical Inspector 5. Plu'mbing Inspector
. Othercontact Person* - Phone #: