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Home My WebLink AboutBLDP-22-006936 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �' CITY YARMOUTH MA DATE June 01,2022 PERMIT# BLDP-22-006936 11- JOBSITE ADDRESS 162 RAYMOND AVE OWNER'S NAME IVERNAVA ROBERT M JR TR OWNER ADDRESS THE RAYMOND AVE TRUST 73 PROSPECT ST SWAMPSCOTT MA 01907 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 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 0 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 I LICENSE# 112298 I SIGNATURE MP 0 MGF ❑ JP 0 JGF❑ LPG' 0 CORPORATION 0#' I PARTNERSHIP ❑#' ILLC ❑#I I COMPANY NAME: ISTEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH I STATE MA ZIP 1026641207 I TEL I FAX 1 1 CELL ) 1 EMAIL 'inspections(d)efwinslow.com 1 _c, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK xn=' ':�„ i= CITY SOUTH YARMOUTH MA DATE 5/20/22 _ PERMIT# �- Z &I 1 ___ OWNER'S NAME ROBERT VERNAVA JOBSITE ADDRESS 62 RAYMOND AVENUE .... I G OWNER ADDRESS SAME .... TEI 781 254 1415 FAX _— _R_ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW:LiRENOVATION:Li REPLACEMENT:' fj PLANS SUBMITTED: YES[J NO LA APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER OM € . BOOSTER CONVERSION BURNER MI 111111111111-011.11.11.111111111111111111MOMANSIV-MM -- COOK STOVE DIRECT VENT HEATER 4F � " _ itM11.11.111111.1111111.1-OM DRYER FIREPLACE MalliallaiMilli SMINII MOM MI mit FRYOLATOR OWL FURNACE 4 GENERATOR GRILLE MIIIIVOIIMMOIMIIIMFIMIICIIIIKIMIIIIIIIPFIIWIIIIIIIIOIIIIIIIIIIIFIIIIIIIIF INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER 111*--M-11.1111.1-4 MI OMIT WINN OM'MI MI 1111.1.111111011111111111 WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO _ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LE OTHER TYPE INDEMNITY ri BOND x 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 Ej AGENT L 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 complian a P rtine Massachusetts State Plumbing Code and Chapter 142 of the General Laws. provision of the PLUMBER-GASFITTER NAME LSTEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP + MGF'- JP Lj JGF El LPGI' r CORPORATION # 281C PARTNERSHIP # 3 LLC #f COMPANY NAME:1E.F.WINSLOW PLUMBING&HEATING ADDRESS'8 REARDON CIRCLE s a CITY SOUTH YARMOUTH ---------- ---�-. . STATE MA ZIP 02664 TEL i 508-394-7778 FAX 508-394-8256 CELL N/A jEMAIL INSPECTIONS EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a Lafayette City Center 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 99 employees (full and/ 5. ❑Retail Il 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. El Non-profit 3.❑ We are a corporation and its officers have exercised 9. El 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 ce • e'the ins and penalties of perjury that the information provided above is true and correct. f/ 12/01/2021 Signature: Y �-'�"" 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): 1 Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia