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G-19-1221 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ; CITY YARMOUTH MA DATE August 28,2011 PERMIT# BLDG-19-001221 JOBSITE ADDRESS 44 FOREST GATE VILLAGE OWNER'S NAME DONNA O'LEARY G OWNER ADDRESS 44 FOREST GATE VILLAGE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO© FIXTURES FLOORS—. BSM 1 2 3 4 5 8 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 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 9 NOD IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF 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. 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 end 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# 3281 SIGNATURE MPO MGF❑ JP❑ JGF❑ LPGID CORPORATION 3281 PARTNERSHIP ❑# LLC❑# COMPANY NAME: E.F.Winslow Plumbing&Heating Co ADDRESS 8 REARDON CIRCLE, CITY YARMOUTH STATE MA ZIP 02664 TEL I FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK \_n- `.._:� .! CITY Y(nM11111 i MA DATE Infrni:l PERMIT#746 - /7 -OW/ „GRESbBBSJTE ADDRESS U4 Fofp5-f 64-eilc.m 'laOI 4OWNER'SNAME 1, nflilct O1-1(4f1 I OWNbERA S SUnit JTEL c)()%11611159 !FAX 1 TYPE OR OCCUPANCY TYPE COMMERCIALQ EDUCATIONAL 0 RESIDENTIAL[-{' PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES© NO0 APPLIANCES 7 FLOORS.. am 1 2 3 4 5 6 7 8 9 10 11 12 1 13 14 BOILER r BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER �- y FIREPLACE _ _ FRYOLATOR FURNACE 1 -. - GENERATOR ' GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN - POOL HEATER ROOM/SPACE HEATER - _ s ROOF TOP UNIT - . TEST UNIT HEATER - UNVENTED ROOM HEATER WATER(EATER - OTHER I _ T _ -_ r- - — A. ' , - ta- INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ElOTHER TYPE 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. O CHECK ONE ONLY: OWNER❑ AGENT 0 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: d accurate to the best of my knowledge '^'r and that all plumbing work and Installations performed under the permit Issued for this application will be in comply e with all Pertinent provision of the CJS :Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -4100 1.—'(-lc PLUMBER-GASFITTER NAME!STEPHEN A.WINSLOW LICENSE# 12298- r SIG ATURE - - MP ID MGF0 JP JGFQ LPGIO CORPORATION©+ # 3281C PARTNERSHIP0# ILLCQ# I f- COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE ?: CITY SOUTH YARMOUTH STATE MA ZIP 02664 f TEL 508-394-7778 FAX 508-394-8256 CELL N/A IEMAIL!accountspayable@efwinslow.com • \ I Ma..a a ILL V.IIIIIII./II M..!SI II eJ tr{..JJIIV.I MJYI.J Department of Industrial Accidents I=a ice_ t Office of Investigations I_111 f . 600 Washington Street Boston,MA 02111 `� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name(Business/Organization/Individual): E•t-f.Wtp 5IOw Y/�tt,,ylj 2, 41to.t. . Qe., briCI Address: 3 (4(yawl Citi _ d City/State/Zip: Sa,sA.v1 Yttirome-At, N}r Phone#: t5tM-399-117Q Are you an employer?Check the appropriate box: Type of project(required): X 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 t 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 .0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.0 Other my applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • -lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. /� usurance Company Name: An-0,,..s tiui-ve..A .sunt*.t (it \n c t ivivi )licy#or Self-ins.Lic.#: VS a[ /fie ��^^ L ," ''11 Expiration Date: t—[ — aof9 Lb Site Address:a3 Cla vvvvsn kg -L r�_ '4 Ct'e34. ptili City/State/Zip: Oa4&,7 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 'up 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 ivestigations I the DIA for insurar - overage veri j on. do hereby certify un • e airs a penalties o p-jury that the information provided above is true and correct. i: otic: - _ 4. t i _ - - - - Date: (a I blot' hone#:-S1' 39'i:797 ' • 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): 1.Board of Health 2.Building Department 3.CityiTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ‘‘‘..N1 Contact Person: • Phone#: t