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HomeMy WebLinkAboutBLDG-22-003610 T MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e c CITY YARMOUTH MA DATE December 29,2021 PERMIT# BLDG-22-003610 JOBSITE ADDRESS 2 CAPT SMALL RD OWNER'S NAME TOLMAN-MICHON HILARY G OWNER ADDRESS 300 E 40TH ST APT 12A NEW YORK NY 10016 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 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 ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER OF INDEMNITY❑ 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 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 0 MGF 0 JP 0 JGF❑ LPG! 0 CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionst7a efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK —Y— -i_ " f ,y CITY YARMOUTH(SOUTH) I MA DATE 12/16/2021 PERMIT# JOBSITE ADDRESS 2 CAPTAIN SMALL RD,S YARMOUTH,MA OWNER'S NAME HILARY TOLMAN GOWNER ADDRESS 300 E.40TH ST, 12A,NEW YORK,NY 02664 1 TEL(917)484-2115 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL J EDUCATIONAL LI RESIDENTIAL El PRINT CLEARLY NEW: RENOVATION:ij REPLACEMENT:ID PLANS SUBMITTED: YES 0 NO APPLIANCES 7. FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ,I ..... Will* 111011 BOOSTER 1 o CONVERSION BURNER e _ _,1 I ,1 COOK STOVE 1111-1,111100.111-1011111111111110111 INN MIK 11111 1111111111.111111111111 ... E DIRECT VENT HEATER '€ I NM IIIIIIIIIMM10111111111111111.111111 DRYER E ,.of _ I _ i ,i[ FIREPLACE 1.1gr FRYOLATOR FURNACE MOM INN t _ewe GENERATOR Mit°$11011111 illiiiiiii Iiii 11111.110111.11111W/IiiIIIII IIIIIIIIIIIIIIIIIIJIIII GRILLE i IIIIIIIIIIIIIIIICIIIIIIIIII .. INFRARED HEATER liiiraMMIIIMBIMilail.1011111 OIIIIIIIIIMIIIIIIIIIIIIIIIIIIIIIIIIIIIF— LABORATORY COCKS MAKEUP AIR UNIT i... IIIIIIIIIII OVEN SIMOMINK INICIIIIIIIIIIIIIMIll MOM POOL HEATER ROOM/SPACE HEATER IliallIMMIIIIIIIII.11111.1111M,111111 OM IIIIIIIIIIIIWIIIIII MINK ROOF TOP UNIT TEST ` UNIT HEATER 011011.1111111111011110111111111111111111IIIIIIIIIIIIIIIIIIIIIIIIIIIII UNVENTED ROOM HEATER iiiii. imilimillimilimilirMilielawiliglarniiMMN WATER HEATER Illit __ am imam ...:... OTHER L. ,..... IIIIIIMINKIIIIINIIIIMMENIRIIIIINIIIIIIIIIIIIII IIIIIIIIIIIIIIMISIIIIIIIIIIII MB 11111111111111111111111111111111111011,1111 111.11111111111111111111111110111111.1111.111111111 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO Li I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY1NSURANCE-POLICY ` , OTHER TYPE1NUEMNIT Li BOND a- 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 Li AGENT 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 compliance a YPprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1,f/ s /4.....7 PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP MGF 0 JP Ej JGF 0 LPG!0 CORPORATION ID#,3281C I PARTNERSHIP #_ LLC U # COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE . CITY [SOUTH YARMOUTH STATE MA ZIP,02664 TEL[508-394-77781 FAX 508-394-8256 CELL N/A 'EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 17 T —==7.14_! 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 99 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, 0 Office and/or Sales (incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. El Non-profit 3.❑ We are a corporation and its officers have exercised 9. D 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, 11.0 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. #1964A Expiration Date:01/01/2023 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 ' ti the ins and penalties of perjury that the information provided above is true and correct. Signature: •Y ' • -...'A 12/01/2021 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 2.0 Building Department 30 City/Town Clerk 4.El Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia