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HomeMy WebLinkAboutBLDG-19-001028 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4,A :,V ?� CITY Yet Mali 144 1 MA DATE WIJbT ( PERMIT#10A —/9"Odinc J�BSITE ADDRESS S6LMG GLS iJGIOHJ J OWNER'S NAME I �iPrlAt r) QOi/ 1 G OWNER ADDRESS It kr_ , .,._ t t , Its�_ . TEt150Qi0iSI (FAX TYPE OR OCCUPANCY TYPE COMMERCIAL A EDUCAT NAL 0 RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YESD NOD APPLIANCES 7 FLOORS--, BSM 1 2 3 4 5 6 7 8 9 10 11 12 , 13 14 BOILER MN - - - SNOW 0W - — — JJ_ BOOSTER r CONVERSION BURNER -- - M COOK STOVE DIRECT VENT HEATER mi ,E DRYER ® - , , . _ _, FIREPLACE FRYOLATORlaI�i I - . FURNACE IMAM M. _ GENERATOR W♦'=M GRILLE Mitra Mi INFRARED HEATER. MI LABORATORY COCKS1.11n - MAKEUPAIRUNIT - --_ �`M OVEN Ml! POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST t. UNIT HEATER a IIME,.. UNVENTED ROOM HEATER a WATER HEATER Ell n. OTHER[ muma� .- - -- - tiS__ - - MS_ p 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❑+ OTHER TYPE INDEMNITY ❑ BOND 0 O 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. • t CHECK ONE ONLY: OWNER❑ AGENT El ^� SIGNATURE OF OWNER OR AGENT a 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 O 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 v, :Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 1 SIGNATURE t� C MP ID MGF❑ JP❑ JGF❑ LPG'El CORPORATION❑• # 3281C PARTNERSHIP 0# ILie❑# �. Pr COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESSI 8 REARDON CIRCLE I f CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 I FAX 508-394-8256 CELL N/A EMAIL accountspayable@etwinslow.com I itv fig Gaff 5 • \ •i.. VV/INIWIi1YYµ8•I1.Vf IIIYJJMYIiMJYfW Department ofIndustrial Accidents _,z'till l Office of Investigations ___'i_ I . 600 Washington Street - Boston,MA 02111'Wz , irwww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ' Please Print Legibly Name(Business/Organization/Individual): E•'r•Wrr�SIO�,,t Q[o,,•,1010c A. t1{0.'-,5 Qe) Int. Address: 3 &eochn Corm City/State/Zip:-SoaAin—lcn.., k, NAr Phone#: 538-399-11'7Sl krg you an employer?Check the appropriate box: Type of project(required): AI 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 .❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling — ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. ❑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 right of exemption per MGL 11.❑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' 13.0 Other comp.insurance required.] ,ny applicant that checks box ill must also fill out the section below showing their workers'compensation policy informatkn. • -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. //��n isurance Company Name: f\ o...) ( ��i't/� irrotnn,n to_ c yly olicy#or Self-ins.Lic.#: i S a Expiration Date: i—) — ao9 rb Site Address:.23 Ginencel'j'eJ h ini-e Ct,e3 (14L11i City/State/Zip: 0,)'4 to 7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). iilure 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 ti.t a copy of this statement may be forwarded to the Office of tvestigations s the DIAfor insura. - overage veri a.on. do hereby certify un e ains a #penalties o p•jury that the information provided above is true and correct • ignat&- • Date: (a)71 I awl hone#: S1)g:359. 777b' 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector • 6.Other Contact Person: Phone#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK All, CITY YARMOUTH MA DATE August 21,2011 PERMIT# BLDG-19-001028 JOBSITE ADDRESS 11 HAWKS WING RD OWNER'S NAME PESSIN GERALD G OWNER ADDRESS ,PESSIN SHEILA R 11 HAWKS WING RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL © PRL'1T 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 0 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR 1 GRILLE • • INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ OVEN POOL HEATER ROOM!SPACE HEATER ROOF TOP UNIT TEST 1 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 0 NOD IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY El 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 end accurate to the best of my knowledge end that all plumbing work and Installations performed under the permtt 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 MPO MGC JP❑ JUL: LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS 8 REARDON CIR, CITY S YARMOUTH - STATE MA ZIP 026641207 TEL FAX CELL EMAIL accountspavableeefwinslow.com r.-• r'. •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 • • M4— 71-jS �/� C ttl.,2