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HomeMy WebLinkAboutBldg-22-001264 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE September 03,202 PERMIT# BLDG-22-001264 • JOBSITE ADDRESS 106 PINE ST OWNER'S NAME DEE RICHARD 0 G OWNER ADDRESS DEE MARY H 106 PINE ST YARMOUTH PORT MA 02675-1839 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES El 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/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 El 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❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsAefwinslow.com SKON M3IA321 Nbrld #11W2j3d $:33d ❑ ❑ 1I11213d 3H1 SV S3A213S NOIiV011ddd SIHI oN sa1 S310N NOI103dSNI 1VNId AlN0 3Sl 210133dSNI NOd 3OVd SIH1 S310N NOI103dSNI SVO HOflO - ~ K0ASSACHUSGTTS UNIFORM APPLICATION FOR/\PERMIT TO PERFORM GAS FITTING WORK CITY � Mk DATE pERM[T# JDB8\TEADDRE8S / �O�NEF�SNA�E ............... � GOWNER ADDRESS _ TEL5V 6I� FAX TYPE OR OCCURANCYTYPE COMMERC|AL�� EDUCATIONAL REG|DENT|AL yIdN7 ~~ -- CLEARLY �1 [-� NEW: --." RENOVATION: REPLACEMENT: PLANS YES NO[] APPLIANCES-1 FLOORS- a8M 1 2 3 4 5 S 7 8 9 i0 11 12 13 14 - � BOOSTER CONVERSION BURNER DRYER FIREPLACE FRYOLATOR GENERATOR LABORATORY COCKS MAKEUP AIR UNIT ~,^., POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT UNIT HEATER In ROOM WATER HEATER __- ' __. [ L /| INSURANCE COVERAGE |have u current liability insurance policy nr its substantial equivalent which meets the requirements oyMGL Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHGRTYPE|NDEMNiTY [—l BOND |-_f 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: OWNERF—| AGENT �� SIGNATURE OF OWNER ORAGENT |hereby certify that all of the details and information I have submitted or entered regarding this applicationthe knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliancof the Massachusetts State Plumbing Code and Chapter 14uuf the General Laws. ^� y /lo°~ =� PLUM8ER,GASF|TTERNAME 8TEPHENVV|NSLOVV LICENSE# 12208 SIGNATURE MP �GF| ( JP| � JGFF-� LPG| � CORP0RAT|8N��# 3281C PARTNERSHIP �# VLLC��#_____ � — ~�~ ~~� --` �� — ---' -- --' [� COMPANY NAME:� E�F'VV|NSLOW PLUMBING 8HEATING ADDRESS 8REARD0NCIRCLE ` -- CITY SOUTH STATE MA ZIP 02684 TELSO8'304�778 A r^ F~ _ FAX 688-384-8268 CELL NIA EMAIL |NSPECT/0NG@EFVVNSLOYVC8M IP The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations i" al T Lafayette City Center tl� M� 2Avenue 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): 1.0 .I am a employer with 90 employees (full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantBar/Eating Establishment 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. ❑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.] 1211 Other *Any 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. #1964A • Expiration Date:01/01/2022 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' el•the ins and penalties of perjury that the information provided above is true and correct. ,fJ l 01/02/2021 Signature:* 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): 1❑Board of Health 2.[]Building Department 3E1 City/Town Clerk 4.['Licensing Board 5.❑Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia