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HomeMy WebLinkAboutBldg-21-001555 '1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 11----- E1 CITY YARMOUTH MA DATE September 25,202 PERMIT#If g BLDG 21 001555 JOBSITE ADDRESS 33 PHYLLIS DR OWNER'S NAME AREVALO CARMEN G OWNER ADDRESS AREVALO ERNEST 524 POPLAR ST ROSLINDALE MA 02131 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 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 1 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 ❑ 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© MGF ❑ JP❑ JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL (inspectionst efwinslow.com r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �u . !_f-�� CITY YARMOUTH � MA DATE 09/11/20 PERMIT# N.DG Z " SS5 ._� JOBSITE ADDRESS 33 PHYLLIS DRIVE,SOUTH YARMOUTH „ 'OWNER'S NAME AREVALO,ERNESTO GOWNER ADDRESS — A TEL[617.529.2879 FAX_ 1 TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 RESIDENTIAL El PRINT CLEARLY NEW:, RENOVATION:Li REPLACEMENT:,,, PLANS SUBMITTED: YES® NO,w. APPLIANCES Z FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER 1 i_ , I. I imit iii CONVERSION BURNER f ' 3 COOK STOVE DIRECT VENT HEATER ( 'WM d I i DRYERi NW IIIIIIIIIIIIIIIJIIIIUINIEIIIIIIIllIllillIllIll111lgIIIIIIIIIIIIIIIIII.Mali FIREPLACE OM Mit OM 1 M MI MOM OM OM UMW FRYOLATOR mainivar11111111111111 W FURNACE � - —� a 11111111.111111 .. '' GENERATOR _..,_.. '. I - ' NM ow 1111111i IIIIII NW GRILLE I� I � INFRARED HEATER IIIIi fI111111111, ��II aiU MW LABORATORY COCKS MIMPI { I -,OM MN MAKEUP AIR UNIT MI 111111011111.11111011111,1111111111111111111111111111111111M111111111111111111 OVEN I _ _ W'._ POOL HEATER ��Ilal . .T I We OW M ROOM/SPACE HEATER I '' :I wma ROOF TOP UNIT MI 1Wl. TEST OO IMP WM 011.1.1.NM MN OW NM Mg 01114 UNIT HEATER ow imirsic�inr' wr—_ un'elimi wiliM11.111 UNVENTED ROOM HEATER NM 1111. 1!___ • 01 SU I EM WATER HEATER OTHER 1111111.11111111.111111111111111.1111111111rilliffildir$11 ' IIIIIIIIIMIIIIIIIIINIIMIMIIMINMIPIIIIIIIIIIIIOIIIIIIIIIIIIIFIIIIIIIIIPIIIIIFIIIIIIFIIIIIIIIIIIIIIIIIIIIFIIIIOIIIIIHIIIICIIIIIISIIIOII � , — I I WMO 536235 '.50.00 . .... III 1 E111111 ION lila 111111111 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Lfj NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Li OTHER TYPE INDEMNITY j BOND Li 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 0 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 and accuratg to the b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc ajYPprtine provisionsi of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -- .••••• ^-„- PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP[] MGF JP.J JGF I:- LPG'Li CORPORATION #13281C PARTNERSHIP LI# 1 LLC LJ#E COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS[8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-398-7778 FAX 508-394-8256 CELL,N/A EMAIL'INSPECTIONS@EFWINSLOW.COM • The Commonwealth of Massachusetts Department of Industrial Accidents isApt —'� Office of Investigations m li lR t _ 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 PLUMBING & 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): 1.111 I am a employer with 90 employees (full and/ 5• 0 Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establament - 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.)employees working for me in any capacity. [No workers' comp. insurance required] 8. 0 Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care 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 has 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 c. 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 of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' 7 the ins and penalties of perjury that the information provided above is true and correct. Signature: ` ` '� 01/02/2020 r Date: Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia