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HomeMy WebLinkAboutBLDG-23-003878 f i<t. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �` 4/ CITY YARMOUTH MA DATE January 17,2023 PERMIT# BLDG-23-003878 JOBSITE ADDRESS 114 SULLIVAN RD OWNERS NAME Kathleen Farley G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: m 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 1 • 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 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# 112298 SIGNATURE MP❑ MGF © JP❑ JGF❑ LPG! ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ISTEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH STATE MA ZIP 02664 TEL 15083947778 FAX CELL I I EMAIL Iinspectionsaefwinslow.com • J A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - `Ii= CITY Yarmouth I MA DATE 1/10/23 PERMIT# 2-7— 397cr gm JOBSITE ADDRESS 114 Sullivan Road I OWNER'S NAME Kathleen Farley GOWNER ADDRESS same TEL 508-414-5675 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT RESIDENTIAL LI CLEARLY NEW:LA RENOVATION:Li REPLACEMENT:ED PLANS SUBMITTED: YES ID NOD APPLIANCES-1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER INN 11111111.1111111 i BOOSTER CONVERSION BURNER OlifirmiliiiliM appijaparlaig IaI , COOK STOVE wig am al giiiiiiiii lig en gig Nog antimi oft gm gm gm DIRECT VENT HEATER ,1111111110111111111111.1111MISIIIIIIIIIIIIIIIIIIIIIIIIIIIMPIIIIIIIIIENI.WWI DRYER 1.111M. IIIIIIMIIIIIIIIIIIILIIIIIIIIIIIIIIIIIIIIIIIIIIIIMIIIIIIIIIIIll FIREPLACE 1111.1111.111RIM low NMI FRYOLATOR IIIIIIMION110.101111.10111111111111111taiiiiiisiliw, FURNACE GENERATOR111.11.1. i` MMIIII.UMW GRILLE lam' 1 INFRARED HEATERmumicautir----amitamosimamit amerwmaiiimaismanione LABORATORY COCKS MAKEUP AIR UNIT ,.. 1 mm--' OVEN IL I int_ R l' I . 1 9..=_ ,rd POOL HEATER AM aMIN gall Mi. ROOM/SPACE HEATER ; ii I ROOF TOP UNIT .l 1 � it _ I li � ��`� TEST MIK UNIT HEATER 1 1 . 1i , UNVENTED ROOM HEATER 0111111,Walli,01111111111111111111111111111111011M111111111111111111111111111111111.11111 WATER HEATER OTHER 11.1110111111W11111101111111111.111111111111111.1114Micanit 1111111101011111111111111111.1111111.111111111111111111111110111111111' INN 1 ..... iimitarniamiannimainairmial sairal. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO LI I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY Li 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 Li AGENT Li 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 comp lianc ajYP rtine Massachusetts State Plumbing Code and Chapter 142 of the General Laws. provision of the -' .......,- PLUMBER-GASFITTER NAME[STEPHEN WINSLOW ]LICENSE# 12298 I SIGNATURE MP Li MGF 0 JP LI JGF 0 LPGI Li CORPORATION Lj# 3281C PARTNERSHIP # J _.. LLC LP COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE,2,,,vi!ti ZIP 02664 TEL 508-394-7778 FAX L508-394-8256 i CELL,N/A !EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts ,r .,,--- Department of Industrial Accidents ,z= = Office of Investigations '' =a10l= 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 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. 0 Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 1 l.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 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. #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 ce • of the ins and Signature: �' and penalties of perjury that the information provided above is true and correct �f/"` ..044,..•--' 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): 1.0Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.['Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia