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HomeMy WebLinkAboutBLDG-23-002285 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE October 27,2022 PERMIT# BLDG-23-002285 it JOBSITE ADDRESS 15 BARNACLE RD OWNERS NAME Andy Faria G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 I 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❑ 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 ❑ JP❑ JGF❑ LPG( ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ISTEPHEN A WINSLOW ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH STATE MA ZIP 026641207 TEL I FAX CELL I EMAIL Iinspectionseefwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK --t"1€L 1 CITY YARMOUTH PORT MA DATE 10/18/22 I PERMIT# JOBSITE ADDRESS 15 BARNACLE ROAD OWNER'S NAME ANDY FARIA J GOWNER ADDRESS SAME TEL 508 326 1244 FAXr---- TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Lj RESIDENTIAL Li PRINT CLEARLY NEW: RENOVATION:EIJ REPLACEMENT:L PLANS SUBMITTED: YES LI NOLij APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER 01111111111111111111011111'101.1111111 1111111110111111111.11111 OM ice: CONVERSION BURNER , _u _ ..'.JMI IIIIIIIIIIMII COOK STOVE a 1 DIRECT VENT HEATER aiii : . y DRYER FIREPLACE FRYOLATOR IMF 1 FURNACE GENERATOR — GRILLE a 'ON Mil 111111 MI Wail Mai iiiii Mir INFRARED HEATER LABORATORY COCKS 11111011M1111111110; MAKEUP AIR UNIT OVEN 01111 OM POOL HEATER " M ROOM/SPACE HEATER MM.Mail 11111 11.110111111 Oil MI illilli OM IS,NM MC MI ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER _ *1110.1110111111111101.111111111.MWOMIMMUM MOM OM, OTHER TEST FOR LOCKED METER , EI MI 3 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ij NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ,:,j OTHER TYPE INDEMNITY LI 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. CHECK ONE ONLY: OWNER 0 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. // • !/ PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE#,12298 1 SIGNATURE MP 1,21 MGF ED JP LI JGF j LPG!I.j CORPORATION j j# 3281C j PARTNERSHIP Di# j Lc # COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE imMAJ ZIP 02664 iTEL 508 394-7778 FAX 508-394-8256 i CELL N/A EMAIL INSPECTIONS EFWINSLOW.COM The Commonwealth of Massachusetts m / Department of Industrial Accidents '��`'lq, '` Office of Investigations y`: Lafayette City Center 1 2 Avenue de Lafayette,Boston,MA 02111-1750 °'11114-1410 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. 0 Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. employees working for me in any capacity. ❑ Office and/or Sales(incl.real estate, auto,etc.) [No workers' comp. insurance required] 8. ❑Non-profit 3.0 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, 11.0 Health Care 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 fme 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 fme 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 • ,f/er the ins and penalties of perjury that the information provided above is true and correct.-L� Signature: Y -. �(/.. 1�... -- 12/01/2021 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 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#• www.mass.gov/dia