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HomeMy WebLinkAboutBLDG-21-001757 ry MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1k4,,,, :-= CITY (YARMOUTH MA DATE October 05,2020 PERMIT# BLDG-21-001757 Ir==" JOBSITE ADDRESS 132 MASSACHUSETTS AVE OWNER'S NAME IRICCI BONNIE J G OWNER ADDRESS 20 GATEWAY RD,#82N YONKERS NY 10703 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ FIXTURES FLOORS BSM 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 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS _MAKEUP AIR UNIT OVEN _POOL HEATER ROOM I 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF 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. 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# 12298SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsta7efwinsiow.com 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK c`Y CITY [.:717114- .............."---------------1 , °,_ MA DATE PERMIT#B4)6.21412/ 7�$'� JOBSITE ADDRESS r `{ � G G�rYIQ✓(� OWNER'S NAME (r n r.7a : S OWNER ADDRESS l �'rltpl�� Q ' ' Y , __...._.._.__ TYPE OR I :TEI�r?y3g 1I6 FAX PRINT OCCUPANCY TYPE COMMERCIAL CLEARLY 0 EDUCATIONAL 0RESIDENTIAL Eg--- - NEW:0 RENOVATION:Q REPLACEMENT:[ APPLIANCES 1 FLOORS 7�©© 4 5 8 PLANS SUBMITTED: YES N0 BOILER _ 8 9 10 ® 14�` 0 mit BOOSTER — - �r r CONVERSION BURNER r- , �vimir �--- �ini�sum �� IMAM* COOK STOVE - -' 1 m 1^min �'� ' Jl iii i iL �i ,�� MINK isism- ow— DRYER �Iim _ j. - DIRECT VENT HEATER j � lues.own 1 � '�"�—111111_ ��,i l i,� m mg FRYOLATOR _ l �!�j - _ �'� FURNACEON S ! � � �, 1h GENERATORLyammillummt,11.111,111110:11.11110.01•1]MI Mt MI UNAmil I1.1.11111 jilt iVit _J ill i n? I � INFRARED HEATER - _.IJP T N_ 11K_11g11.e1111r,1o1i11i-w1 LABORATORY COCKS mml1i._tm- i - 1' i 11 MAKEUP AIR UNIT ,_ 1Ij GOON moi ', ' .1 > '; ROOMH SPACE HEATER i-. l, ,I! ;;n ; lbm n ', ROOF TOP UNIT r MIN Mk OK limn]milmilinitill. as ins UNVENTED ROOM HEATER r; 1 as WATER EATER l ;' ii;� , OTHEMD'MIR _ ' '111 ` > i i 1111111.11.1111ailiatillit -11111.1111111111111111 I have a current liabi insurance policyINSURANCE COVERAGE L :1111111 or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO Lj I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ED OTHER TYPE INDEMNITY 0 BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter of the Massachusetts General Laws,and that my signature on this permit— aplication wa vea this requirement CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submittedandallwork or entered regarding this application are true and accurat to the Massachusetts State Plumbing Code and Chapter 142 of the Ge r thepnereal Laws for this application will be in compAaa prt of my krro�Medge / provision of the — PLUMBER-GASFiUER NAME STEPHEN WINSLOW -, LICENSE# 12298 SIGNATURE MP Q MGF Q JP El JGF El LPG!Ej CORPORATION + # c- COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING Ellie PARTNERSHIP # LLC 0#ADDRESS a REARDON CIRCLE CITY SOUTH YARMOUTH STATE ZIP 02664 TEL 50:'3' 4778 ; _ _ FAX 508-394-8256 CELL N/A -- EMAIL INSPECTION4EFWINSLOWCOM----- ---.. L 5 The Commonwealth of Massachusetts Department of Industrial Accidents _mti G Office of Investigations a =1,7111E3 111= Lafayette City Center 2 Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: E.F. WINSLOW PLLMBING & HEATING CO, INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 • Are you an employer? Check the appropriate box: Business Type(required): 1.Et-I am a employer-with-90 employeescfull and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating-Establishment 2.❑ I am a sole proprietor or partnership and have no 7, 0 Office and/or Sales(incl. real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation hes other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. #1909A Expiration Date:01/01/2021 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under § 25A of MGL . 152 can lead to the imposition of criminal penalties of a fine 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 of up to $250.00 a day against the violator. Be advised that a copy o this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer • e the ins and penalties of perju that the information provided above is true and correct. Signature: r "` ��-� Date: 01/02/2020 Phone#: 508-394-7778 Official use only. Do not write in this area,to be comp!=ted by city or town official. City or Town: Permit/License# Issuing Authority(check one): 1.12Board of Health 2.❑Building Department 3.11 City/Town Clerk 4.['Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: .mass.gov/dia