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HomeMy WebLinkAboutBLDG-22-006524 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r' 7: CITY 'YARMOUTH I MA DATE 'May 12,2022 PERMIT# BLDG-22-006524 tr_, z° JOBSITE ADDRESS 116 AURORA LN OWNER'S NAME 'Jeannie Donahue G OWNER ADDRESS 16 AURORA LN SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL.II) CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ 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 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 ❑ 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 I LICENSE# 112298 I MP III MGF 0 JP[3 JGF❑ LPG' 0 CORPORATION El#I I PARTNERSHIP 0# SIGNATURE COMPANY NAME: ISTEPHEN A WINSLOW I I 0#I I ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH I STATE IMA I ZIP 1026641207 I TEL I FAX 1 J CELL I I EMAIL IinspectionsAefwinslow.com i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ffial(f�„t CITY YARMOUTH(SOUTH) 1 MA DATE 5/9/2022 --(PERMIT# ZZ, b 5Z L, JOBSITE ADDRESS 16 AURORA LN,S YARMOUTH,MA 02664 OWNER'S NAME JEANNIE DONAHUE GOWNER ADDRESS SAME 1 TEL(781)718-5282 JFAX TYPE OTR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRI CLEARLY NEW:EjRENOVATION:ID REPLACEMENT:El PLANS SUBMITTED: YES 0 NOD APPLIANCES Z FLOORS—I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER J CONVERSION BURNER ' - _ - = 1` COOK STOVE DIRECT VENT HEATER ; DRYER ... 11111111 MK 01.11111111111111111111111,11.111NM FIREPLACE s� f,..., -,.:,- .f .,.f FRYOLATOR : 1 1 I 1 . FURNACE . v. 111111 GENERATOR � ®. �. .. GRILLE i 1 . 11111.111.11 MI OM, INFRARED HEATER 1 LABORATORY COCKS " MAKEUP AIR UNIT ,. a ._.1 _ . 1,.. . a �. e-.,. iI -.- . ,. .,.µ.. 1..: m„ OVEN POOL HEATER MAN NM alliltilall MI Mr 111111111.11,1M111111MONIS NMI all ROOM/SPACE HEATER 6 1 9 a , im, ROOF TOP UNIT .,,.. ' TEST ' 011111.11111111111111-111* UNIT HEATER UNVENTED ROOM HEATER WATER HEATER :. ... [. ,j morn OTHER E1111011.111111111111111111111111111.111111.111111111111 sou., Taitimearammoaramorimitalatimionlii111111 NW. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE_POLICY El OTHER TYPE 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 CHECK ONE ONLY: OWNER AGENT Ej 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 t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc a P�ertine Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _.J!+ provision of the PLUMBER-GASFITTER NAME STEPHEN WINSLOW "� LICENSE# 12298 SIGNATURE MP LI MGF Ei JP Ei JGF 0 LPGI 0 CORPORATION #[3281C PARTNERSHIP[,)# LLC ID# 1 COMPANY NAME:.E.F.WINSLOW PLUMBING&HEATING 1 ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 ITEL 508-394-7778 FAX 508-394-8256 J CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations W.611'9 Lafayette City Center = � .` 2 Avenue de Lafayette, Boston,MA 02111-1750 wwx.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. 0 Retail or part-time).* 6. 0 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]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑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 ft 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 ce ' e the ins and penalties of perjury that the information provided above is true and correct. Signature: R-� Y Date: 12/01/2021 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): 1fBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia