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HomeMy WebLinkAboutBLDP-23-005666 GAS MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r' CITY YARMOUTH MA DATE April 11,2023 PERMIT# BLDP-23-005666 JOBSITE ADDRESS 300 BUCK ISLAND RD UNIT 20A OWNERS NAME COSENTINI CARYN E G OWNER ADDRESS C/O JOSEPH MAIDA 83 DON BOB RD STAMFORD CT 06903 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO 111 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 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 1 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# 112298 SIGNATURE MP❑ MGF 0 JP El JGF❑ LPGI El CORPORATION El# PARTNERSHIP El# LLC ❑# COMPANY NAME: ISTEPHEN A WINSLOW ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH STATE MA ZIP 102664 TEL 15083947778 FAX 1 1 CELL 1 EMAIL Iinspectionsna.efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1f�y CITY Yarmouth MA DATE 4/6/23 PERMIT# , • JOBSITE ADDRESS 300 Buck Island Road Unit 20A 'OWNER'S NAME 'Caryn Cosentini • G OWNER ADDRESS same I TEL[917-621-6561 —"FAX=, . TYPE OR OCCUPANCY TYPE COMMERCIAL L1 EDUCATIONAL Li RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:0 REPLACEMENT:Ld PLANS SUBMITTED: YES LI NO 0 APPLIANCES 7 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER a BOOSTER I; imi.. 111111111111. I- b CONVERSION BURNER -': -- COOK STOVE NM � i , , . .._ -. : �._ .. DIRECT VENT HEATERl DRYER FIREPLACE ' FRYOLATOR FURNACE ' GENERATOR i . GRILLE INFRARED HEATER LABORATORY COCKS „ „ MAKEUP AIR UNIT NM 1.11111111111.111111 OVEN POOL HEATER 1111111.1111.11M11111.101.110.11.111.11111111011111111011-1. ROOM/SPACE HEATER =1 .._. ROOF TOP UNIT Mil 1 — TEST ;111111011111111011iiiiliameimi sort low ....._. Oil UNIT HEATER s ..w.. i UNVENTED ROOM HEATER a; - IMAM MINIC m WATER HEATER t OTHER WIENIE.-. _. .�. .W.� 1 .. .... ._ n 1 I ie, INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Ej NO rai I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIA ILITYINSURANCEPOLiCY „ OTHER-TYPE INDEMNITY 0 BONO 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 U AGENT Li 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 accurat 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 ajl�P dine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 71/f/ * !/ Y �- PLUMBER-GASFITTER NAME STEPHEN WINSLOW 1 LICENSE# 12298 SIGNATURE MP MGF Li JP Li JGF Li LPG!D CORPORATION IL1# 3281C i PARTNERSHIP # �LLC #L COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS LBIREARDON CIRCLE CITY SOUTH YARMOUTH - STATE MA J ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 1 CELL N/A 'EMAIL INSPECTIONS@EFWINSLOW=COM The Commonwealth of Massachusetts Department of Industrial Accidents �,_.tt,)-0=1„— =pOffice of Investigations '` =qf ii 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.❑■ I am a employer with 120 employees (full and/ 5. ❑Retail or part-time).* 6. ❑ Restaurant/Bar/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]** MO 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 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:23 Commonwealth Avenue City/State/Zip: Chestnut Hill, MA 02467 Policy#or Self-ins. Lic. #2019A Expiration Date:01/01/2024 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. Signature: `^\ T p 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 3.0 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia