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HomeMy WebLinkAboutBLDG-21-004237 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4"I -` January BLDG-21-004237 � �� CITY YARMOUTH MA DATE 29,2021 PERMIT# JOBSITE ADDRESS 27 AUNT EDITHS RD OWNER'S NAME WILLSEY LANCE G OWNER ADDRESS WILLSEY PAMELA J 1 NEWBROOK CIR CHESTNUT HILL MA 02167 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO ED FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 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 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © 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 ❑ JP❑ JGF 0 LPG' ❑ CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsRefwinslow.com J MASSACHUSETTS UNIFORM FOR A PERMIT TO PERFORM GAS FITTING WORK -? 'fi= t= CITY 7 . u► . �] r�m�� ...`_...�.��� ..�_ � �! MA DATEir, L�.y I TI- PERMIT# r7LDC�" 'Z/ -OD 37 JOBSITE ADDRESS++11 ter► t d,?•b,, Q „ Sovj Kano✓ j OWNER'S NAME Ls v i7 -(.10 iC- , G OWNER ADDRESS 0Wo L L 5a,T1'I• 44/4/0444 JSa66 _ I TE 50$7 S012/2 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL El _ RESIDENTIAL L -- PRINT CLEARLY NEW:0 RENOVATION:Li REPLACEMENT: PLANS SUBMITTED: YES ID NOD APPLIANCES 1 FLOORS- 9SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 ��_ �� — _ - __ .__�.,...-_ _..__- _- r BOILER �! �.,.8 , , S. „ . ._ ,. I --,3 BOOSTER i —� E � I' �.m ` W �. Illt 1.. �., _ CONVERSION BURNER i 1, , , , i .1 COOK STOVE . .,..,�.�_1, DIRECT VENT HEATER - f 1_ ; - _ 1 _ DRYER . m_l �. , Ij {{ ,�� f _.�..T` "`Y:� - �' ,i'slfiliYci w.;, - - ::1„_ e^r 4 me 1...--,,. FIREPLACE - FRYOLATOR .._ ,, f ,,..I' !I 1 11. .,. .. ____..._:.i,_ - 1=:, FURNACE 1, _ 1 I 1 ,!(_ _ • 1 -I[- I GENERATOR • 1 _ ! Z__ __ - ! f I GRILLE s I ' �1 -ii .,.��_�._xf H,,IE� ! I' I„A_I.�. INFRARED HEATER i ,, �I . ,.I`..w.,.,- „1 I 1 1i .1 _ G. _ LABORATORY COCKS ._r___I _ `��M. „.. ,M=..._i t_ �_I.�.-�__ -I MAKEUP AIR UNIT 1 - _� + irn OVEN Imo.. i i I POOL HEATER I _f� l l V` 1 .,.,a.▪ ' `I( - .. ROOM/SPACE HEATERI yi�� _ 1 ROOF TOP UNIT ,11,-J1--„,7,..,-;_c„-7-;, __,--1 _ ..,. ! _ ..I�,:s,-. � a . .._ ... .._w�JJlll!li!!1__Jr�._.. � . �, . . ,� I' �� �f:.�LI_ TEST � - --- ,. - —_. .�..I UNIT HEATER i I VI 1 I.. I I ffi.w� E-.. .I UNVENTED ROOM HEATER , - �( _G r�—�' 1 .�:I I� WATER HEATER w - I OTHER i� d i :,:. vr„ ,_.. Kcal... ,.f.,..___T. LT] ._.; ,„ - i _ .{i ..,:;::1 INSURANCE COVERAGE 'i r( 1 i I have a current liability insurance policy or its substantial equivalent which meets the requirements of M . o i 142-.,. YES Ii NO / BUILDING GFa" I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL+ BY 7 t'/IE: ' tf LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY 0 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 Li AGENT ID SIGNATURE OF OWNER OR AGENT r-. 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 4. 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 _„ Qy LICENSE# .-p aJ SIGNATURE MP FA MGF El JP LI JGF{-j LPGI[--] CORPORATION[J#L. .s.PARTNERSHIP Lifiim..,_.�._.1 LLC[]#I-7- ,...._,_...1 - COMPANY NAME: ADDRESS CITY ,. _.m._........_ _v,.... �u,._._...........�.�- _,.y.....-...... . STATE ZIP ]TELL _ - -- _____] FAX L ]CELL EMAIL-._ �� The Commonwealth of Massachusetts z xj Department of Industrial Accidents Office of Investigations r `' L �. Lafayette City Center '''‘. j 2 Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Worlers'Compensation Insurance Affidavit: General Businesses A licant Information Please Primt_L Business/OrganizationName:E.F.WINSLOW PLUMBING&HEATING CO, INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH Phone#:508-394-7778 Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with190 employees (full and/ 5• 0 Retail or part-time).* I_" 2•ElI am a sole proprietor or partnership and have no 6. ❑Restaurant/Bar/Eating Establisiunent 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 3.❑ [No workers' comp.insurance required] 8. El Non-profit We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have no employees. [No workers' comp.insurance required]** 10 0 Manufacturing a 4.❑ We are a non-profit organization,staffed by volunteers, 11 0 Health are with no employees. [No workers' comp.insurance req.] 12.0 Other *Any applicant that checks box#1 moat 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 polio in ormati Insurance Company Name: MUTUAL INSURANCE COMPANY y f °n' Insurer's Address: I City/State/Zip: e ___ Policy#or Self-ins.Lie.#1964A ExpirationAttach a copy of the workers'`compensation policy declaration page(showing the policy nu ber0and0 expiration iration date). Failure_to.secure_coverage_as.required under- .25. c. P to$1,500.00 and/or one-year•imprisonment,as well as civil penalties 52 a in theform of a STOPead to the 1WORK of criminal-penalties of a fine-up pp $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of DER a fine Investigations to the DIA for insurance coverageverification. of I do hereby certify un he &i and p naloties o perjury that the information provided above is true ue and correct. Si nature: o 01/02/20 21 Phone#: 508-394-7778 Date: • 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 ono : 10Board of Health 2.0 building Department 3 5•[]Selectmen's Office 6.[]Other '�City/Town Clerk 4.[]Licensing Board Contact Person: Phone#: www.mass.gov/dia