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HomeMy WebLinkAboutBLDG-23-003876 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY IYARMOUTH MA DATE (January 17,2023 PERMIT# BLDP-23-003876 I JOBSITE ADDRESS 116 SPINNING BROOK RD OWNER'S NAME IBADACH AMY E G OWNER ADDRESS 16 SPINNING BROOK RD SOUTH YARMOUTH MA 02664 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL D PRINT RESIDENTIAL El 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 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❑ 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# 12298 SIGNATURE MP❑ MGF El JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ISTEPHEN A WINSLOW ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH STATE MA 'ZIP 102664 TEL 5083947778 FAX CELL EMAIL inspectionsOefwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 5==st_- Fiwc CITY [Yarmouth I MA DATE 1/10/23 I PERMIT# 7.,3fSV.% JOBSITE ADDRESS 16 SpinningBrook Road GOWNER'S NAME Amy Badach OWNER ADDRESS same TEL508-394-4618 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL LI RESIDENTIAL U PRINT CLEARLY NEW:LiRENOVATION:LI REPLACEMENT:Ej PLANS SUBMITTED: YES 0 NO UJ APPLIANCES Z FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER I i� .. CONVERSION BURNER 1 COOK STOVE DIRECT VENT HEATER C DRYER ... " FIREPLACE y B FRYOLATOR . �. . __ €tJRNACE � GENERATOR GRILLE INFRARED HEATER R LABORATORY COCKS 1.111MIMMINIIIIIIIIIIMIll Mill MINN INN 1111111MM 7-- MAKEUP AIR UNIT OVEN allitlallipilliMl POOL HEATERININIONIIMM Ili _ ROOM/SPACE HEATERt, e aE i' i,: .. i ROOF TOP UNIT MI I i NM .. ... TEST UNIT HEATER UNVENTED ROOM HEATER [� ma ' IMIPMI { .... '1 alliall._iiikaigli WATER HEATER ' OTHER tammimio,imiitmmeimoimc sat .::....Lm mar mit mat immir INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LI NO LI I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Li OTHER TYPE INDEMNITY D BOND LI OWNERS INSURANCE WAIVER:I am-aware-Mat the-licensee does not have the insurance coverage required Gy Chapter 142 of the — Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER rj 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 complianc a Pprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ( ,f/, .....l.--- PLUMBER-GASFITTER NAME—STEP—HEN WINSLOW i LICENSE# 12298 SIGNATURE MP MGF JP JGF LPGI CORPORATION -._I # 3281C PARTNERSHIP # LLC LI# COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL508-394-7778 — FAX i 508-394-8256 I CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents r l9 � Office of Investigations —(,'' Lafayette City Center Si � 2 Avenue de Lafayette, Boston,MA 02111-1750 li*"' 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): 1.0 I am a employer with 120 employees (full and/ 5. 0 Retail 2.0 or part-time).* 6. 0 Restaurant/Bar/Eating Establishment I am a sole proprietor or partnership and have no 7El Office and/or Sales(incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. 0 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, MD 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:23 Commonwealth Avenue City/State/Zip: Chestnut Hill, MA 02467 Policy#or Self-ins. Lic. #2019AExpiration 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 ce ' e the ins and penalties of perjury that the information provided above is true and correct . / Signature: r#f-. ......04 - 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): 1fBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.OLicensing Board 5.0 Selectmen's Office 6.0Other Contact Person: Phone#: www.mass.gov/dia