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HomeMy WebLinkAboutBLDG-19-001249 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE August 29,2011 PERMIT# BLDG-19-001249 JOBSITE ADDRESS 158 THACHER SHORE RD OWNER'S NAME 'AYLMER DAVID H G OWNER ADDRESS HUCKINS JOAN E PO BOX 54 YARMOUTH PORT MA 02675-0054 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES❑ NO© FIXTURES FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: 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 CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY❑ 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 SIGNATURE OF OWNER OR AGENT I 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 Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP© MGC JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL accountspavableaefwinslow.com 4 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE:$ PERMIT# PLAN REVIEW NOTES `c et CITY 7 0.I'M 0V}-Ln I MA DATE 43las PERMIT# — /9—— 0 0 /al yy G JOBSITooEADDRESS J%t?nElhtl!I Statile Rc).ttiafnlV)4OWNER'S NAME I David �f l hf1 • IOWNERADDRESS [ Shin f TEfISQ%36ag300 IFAXI TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NOD APPLIANCES 1 FLOORS-+ BSM 1 1 I 2 I 3 I 4 1 5 1 6 7 I 8 1 9 I 10 11 12 13 14 BOILER - BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER L. --- DRYER FIREPLACE - FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS _ __ MAKEUP AIR UNIT OVEN !_ POOL HEATERVi4 ROOM!SPACE HEATER ' _ _ ROOF TOP UNIT TEST . 90 ' �.. UNIT HEATER UNVENTEDROOMHEATER '- _ .--. •:77741 Er'f - - _ - WATERHEATER OTHER I ■ S1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW' LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY 0 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 Q AGENT 0 SIGNATURE OF OWNER OR AGENT K." I hereby certify that all of the details and Information I have submitted or entered regarding this application are rue nd 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 co p' nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ) -oma y- / PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE 12298 SIGN TURE 5.cr' MPD MGF❑ JP❑ JGF❑ LPG!❑ CORPORATIONQ# 3281C PARTNERSHIP❑# JLLC D#I • 1 C tr. COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESSI 8 REARDON CIRCLE CP S CITY SOUTH YARMOUTH ! STATE MA ZIP 02664 TEL 508-394-7778 CF FAX 508-394-8256 CELL N/A !EMAIL accountspayablenaefwinslow.com E �3 • .\ 1164 VVII61I6VIO IYL666606 j yrJ66VJM466N.6466J 1 ew== l Department of Industrial Accidents 6 ` . o"moi= Office of Investigations Mite MS 600 Washington Street • - Boston,MA 02111 •� .---' www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers applicant Information Please Print Legibly \Tame(Business/Organization/Individual): E.C.WirtS1O, Q(u .j0t A. tl.co\ .'v Qe) Irlt. kddress: $ &eodwl C2 dQ.. OY ity/State/Zip: Soo ycvi„r,,,(-t„ NA" Phone#: 'OR-394-Miii Nre you an employer?Check the appropriate box: Type of project(required): atI am a employer with 70 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 0 I am a sole proprietor or partner- listed on the attached sheet.I 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions ❑ I am a homeowner doing all work ,ript of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152;:'§1(4),and we have no„ ,12.❑Roof repairs insurance required.]t - employe€s.[Ido woil ers-: , comp.insurance required.] • 13.0 Other ry applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • omeowners who submit this affidavit indicating they are doing alt work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of thesob-Contractors and their workers'comp.policy information. mon employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 9rmation. n n urance Company Name: Pi .,i Nokod\ (/3tUCt ii fat C vai icy it or Self-ins.Licc.(.�'#: '13 a I Expiration Date: (—I — oaOl� -1K\ Site Address:a3 Cs3fw u n v-^e0.141s Atmi Ct k4y{6 I U City/State/Zip: Dao ta 7 :ach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 3 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 ip to$250.00 a da a ainst the violator. Be advised t t a copy of this statement may be forwarded to the Office of ( L estigations the DIA for insura overage yeti a on. \ 2 hereby certify un ns a penalties o4p jury that the information provided above is true and correct. v (� net& ' A fJ Date: I . ,311aot7 • me#: cbt 3'4. 7978 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 5.Other Contact Person: Phone#: e