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HomeMy WebLinkAboutBLDG-23-000446 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �' 'c CITY YARMOUTH MA DATE July 27,2022 PERMIT# BLDG-23-000446 JOBSITE ADDRESS 18 CURVE HILL RD OWNER'S NAME HUNT JOSEPH G OWNER ADDRESS HUNT JUDITH 18 CURVE HILL ROAD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 . 0\1111111) FRYOLATOR , FURNACE GENERATOR 1 P . \ \ GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ` , OVEN ,r,s1 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 0 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# 112298 SIGNATURE MP© MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION 0#I PARTNERSHIP ❑# LLC 0# COMPANY NAME: ISTEPHEN A WINSLOW ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH STATE MA ZIP 1026641207 TEL I FAX I CELL ( I EMAIL inspections(D,efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1°6".^� CITY [-YARMOUTH(SOUTH) 1 MA DATE 7/22/22 I PERMIT# 2 3 6 y y 4 JOBSITE ADDRESS 18 CURVE HILL RD,S YARMOUTH,MA 02664 OWNER'S NAME JOSEPH HUNT GOWNER ADDRESS SAMEII— TEL(508_1394-2131 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL Lj PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO El APPLIANCES 7 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i � _ .,.: me F ._.:,..:, BOOSTER mm ..... _i CONVERSION BURNER ' ' COOK STOVE DIRECT VENT HEATER _ _. 111111 DRYER _ . _ l FIREPLACE a €RYOLATOR , FURNACE ' ... aI T --.-,.-_. -1 - -51.111- 1 GENERATOR , 1 ; 1, , 1 w i . .a„ GRILLE i INFRARED HEATER LABORATORY COCKS e MOMMINIMISIIIII MAKEUP AIR UNIT ... �, OVEN el aliallnallatirilliallailinallinallli.10011111111/11 POOL HEATER ROOM/SPACE HEATER ._.. 1i. ROOF TOP UNIT 1011111111111111.101101M1001111111111110011111.11MOMINININIO TEST _ 4 [... .,a ... NIMINIMMIllilai UNIT HEATER UNVENTED ROOM HEATER IMIVOIIIIIIIIMIIIIIIIIOIIMIIIIMIMIIJMIIIWINIIIIMIIOIIIIII WATER HEATER OTHER IFIRE PIT mri I 11111.1111111.1111.11111111111111M11.11010111.11111111111J111111.1M1011~10.111.1111101111. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ra 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 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 j j 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 P�ertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f/ • !/ PLUMBER-GASFITTER NAME 1 STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP MGF 0 JP 0 JGFEj LPGI U CORPORATION # 3281C PARTNERSHIP# LLC 04 COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH j STATE MA-1 ZIP L02664 TEL 508-394-7778 FAX 508-394-8256j CELLI N/A EMAIL NSPECTIONS@EFWINSLOW.COM / The Commonwealth of Massachusetts ' Department of Industrial Accidents '_I! Office of Investigations , =; . _ Lafayette City Center Amara `a - ,r 2Avenue 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 BarrEating Establishment 2.❑ I am a sole proprietor or party rship 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. El 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]** 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ 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 er the ins and penalties of perjury that the information provided above is true and correct ,{/ / Date: 12/01/2021 Signature: Y "`'`-^' 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 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia