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HomeMy WebLinkAboutBLDG-23-005079 UNIT C ��. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK iii 11 CITY YARMOUTH MA DATE March 15,2023 PERMIT# BLDG 23 005079 JOBSITE ADDRESS 1923 ROUTE 6A UNIT C OWNER'S NAME (CHAPTER TWO LLC G OWNER ADDRESS C/O IVANA LIEBERT PO BOX 206 YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES ❑ NO 111 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 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 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# '12298 SIGNATURE MP❑ MGF © JP❑ JGF 0 LPG! ID CORPORATION❑#I PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH STATE MA ZIP 102664 TEL 15083947778 FAX I ICELL 1 IEMAIL linspectionseefwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4 `;�. I®3� _ CITI .' IUTH MA DATE 3114123, - m,— PERMIT# t. � , , JTE Di•ESS 923 ROUTE 6A BLDG#1 UNIT C OWNER'S NAME CHAPTER TWO LLC JIM BASLER .... L. OWNER 'ID"ESS SUNFLOWER MARKET PLACE TEL 508-77.6-8097 LIFAX BUILDING Dt ARTMENT By'TYPE jR TYPE COMMERCIAL EDUCATIONAL [j RESIDENTIAL PRINCLEARLY NEW:Li RENOVATION:Li REPLACEMENT: !.. PLANS SUBMITTED: YESLJ NOLA APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i 't I - L, BOOSTER 7 & - J ..111111,:.:,_. 1 .: . 1r ..A _ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER i r--- I DRYER I __.:€ 11- ._ .._: E_.._ .._ = ., ... . ; 1 s d° I.. ." FIREPLACE I. ` . _ __ FRYOLATOR i ' FURNACE l 1 ,.. l -- r I GENERATOR ._.... 1I. .. . GRILLE . `� i ' INFRARED HEATER , _ LABORATORY COCKS -s... _ .. 2[11 — `--•- - , MAKEUP AIR UNIT - OVEN 1011111001111111111111111110111M1.111101101111111111111111111111111111111111111111W POOL HEATER 111,111. ROOM I SPACE HEATER IIMIIIIIIMINVIMMIalltililliallAiliallitalitIMMOMIXIM ROOF TOP UNIT IMIIIIIIIIINIJMIMMIMMICIIIIIIIIIIIIII,011111M0111 TEST .. UNIT HEATER NIS MI orUNVENTED ROOM HEATERxfmn::-r-_-_„ ram R WATER HEATER �� ;` 1, OTHER.- __ . _ _. a. IR ` INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 NO Li I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Lij OTHER TYPE INDEMNITY El 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 Lj AGENT 0 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 aJYP dine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Y ......4.— __ PLUMBER-GASFITTER NAME j STEPHEN WINSLOW _ LICENSE# 12298 1 SIGNATURE MP ii MGF Li JP D JGF L I LPGI Lj CORPORATION[J#[3281C [j PARTNERSHIPD# LLC;]# COMPANY NAME E-F,WINSLOW PLUMBING&HEATING ADDRESS k 8 REARDON CIRCLE J CITY `SOUTH YARMOUTH STATE MA jZIP 02664 _LjTEL[508 394-7778 FAX`,,508 394 8256 1 CELL1 N/A EMAIL INSPECTIONS@EFWINSLOW COM - —,w—; ,.-- The Commonwealth of Massachusetts Department of Industrial Accidents =,,,..,t_. 9=7�h� Office of Investigations Y Lafayette City Center _=.�®�j 2 Avenue 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 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. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 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.] 12.0 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 cer ' e the ins and penalties of perjury that the information provided above is true and correct. Si ature: �.1� 7 L .4."'`''-'" Date:• 01101/2023 f� 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): I.❑Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.0Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia