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HomeMy WebLinkAboutBLDG-23-004039 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -I CITY (YARMOUTH MA DATE (January 23,2023 PERMIT# BLDG-23-004039 `1rr- JOBSITE ADDRESS 116 WEIR RD OWNER'S NAME (DEXTER JEFFERSON S TRS G OWNER ADDRESS DEXTER DINA G TRS 16 WEIR RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT PLANS SUBMITTED: YES CI NO El NEW: ElRENOVATION:❑ REPLACEMENT:CI 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 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# 112298 I SIGNATURE MP❑ MGF © JP 0 JGF❑ LPG' El CORPORATION❑#I I PARTNERSHIP ❑#I ILLC 0#I COMPANY NAME: ISTEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH I STATE IMA I ZIP 102664 I TEL 15083947778 FAX CELL 1 1 EMAIL Iinspections[7a.efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK M sys1S sl CITY Yarmouth _ l MA DATE 1/16/23 PERMIT# 2. 6/03? JOBSITE ADDRESS€16 Weir Road 1 OWNER'S NAME Dina Dexter 1 GOWNER ADDRESS same TEL 508-685-6048 'FAX . TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL ij EDUCATIONAL RESIDENTIAL ID CLEARLY NEW: RENOVATION:Li REPLACEMENT:LI PLANS SUBMITTED: YES 0 NO11 APPLIANCES Z FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER NM IIIIIIIIIIIIIIIINIIIIII '. 110111111111 BOOSTER SIIIIIIIIIIII 1.11111111111111111115111111111 CONVERSION BURNER vitsairomI _ i ,�I I m COOK STOVE ;: . DIRECT VENT HEATER DRYER 1111111111111111111111111111111111WWIIIIIIIIIIIIIWINIIIIIIMIIIIIIMIUMIIIIII_ FIREPLACE FRYOLATOR IIIIIIIIIII.Illilliall IIMIIME11111OnIwrwrimmiNcli FURNACE OIMMOMNJONISMNIIIIIMMMNISIIIIIIOOMIIIIMWIIIIIIHMIIIINMIIMIIIIIIISIIIIIFIMM GENERATOR .- GRILLE x i , ,� E INFRARED HEATER 0111111111111MMININ 1111WMININION LABORATORY COCKS i MAKEUP AIR UNIT ; 1.11111.1.111 MIN IIIIIIMI OVEN POOL HEATER - . { t IIIIIIIIIIIIII 01111111411.11.MI aIIIIII ROOM/SPACE HEATER ROOF TOP UNIT iiir NM MI TEST - Ill IIIIIIIIIIMIIIIIIIIIIIIII NMI _ _ UNIT HEATER illiaimaimiiiM,ainag....: ,_.. 1 ... .. : : ._ iL ..:...._ UNVENTED ROOM HEATER 11110111111111MF. i WATER HEATER al WINK: i J - . .._ IIIIIIIIIIIIIIIIIIIIIIIIIIIIII Ia IlIllNII.XIMIIIII 7-1 INMaaaIMIIIIMMMIMMRal. ..:.." i!.. k . ... .: INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO Li I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Li BOND Li OWNER'S1NSURANCEWAlVER:r am aware that the licensee does not have the insurance coverage requWed by-Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ,, I AGENT U 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 complian a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (�./71 • !j PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE#112298 SIGNATURE MP Li MGF- JP JGF 0 LPG! CORPORATION[ # 3281C PARTNERSHIPL# LLC L # � COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA ZIP02664 TEL 508-394-7778 I FAX 508-394-8256 I CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents .1.‘41 MCiiile=7.!, Office of Investigations _ Lafayette City Center * =n '� t 2 Avenue de Lafayette, Boston,MA 02111-1750 au, ww».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): LE 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. 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 *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: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 cent the ins and penalties of perjury that the information provided above is true and correct. Signature: Y '` ...�^--- 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): 1.0Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia