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HomeMy WebLinkAboutBLDG-23-004283 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY IYARMOUTH k, MA DATE (February 02,2023 PERMIT# BLDG-23-004283 JOBSITE ADDRESS 149 CARRIAGE LN OWNER'S NAME ICOLMER KENNETH G OWNER ADDRESS COLMER LORI ZITO 49 CARRIAGE LANE YARMOUTH PORT MA 02675 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT PLANS SUBMITTED: YES 0 NO El NEW: ElRENOVATION:❑ REPLACEMENT:❑ FIXTURES FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ' BOOSTER ' CONVERSION BURNER ' COOK STOVE 1 ' _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 ' 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 El BOND El 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 I SIGNATURE MP 0 MGF © JP 0 JGF 0 LPGI 0 CORPORATION❑#I I PARTNERSHIP 0#1 ILLC ❑#I I COMPANY NAME: ISTEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR,8 REARDON CIR I STATE IMA I ZIP 102664 I TEL 15083947778 I CITY IS YARMOUTH I FAX CELL EMAIL Iinspections(a,efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK "iV - —1 MA DATE 1/27/23 PERMIT# s =`ski , CITY Yarmouth JOBSITE ADDRESS 49 Carriage Lane -"OWNER'S NAME Ken Colmer [ GOWNER ADDRESS same TEL508-362-1357 FAX TYPE OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL Li CLEARLY NEW:0 RENOVATION:U] REPLACEMENT: PLANS SUBMITTED: YES 0 NOD APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER Nil IMO IOU NMI •... . . NM 11111 VIM r—NM NM NMI BOOSTER i l ,,11111 CONVERSION BURNER 1.11111 _ ... . COOK STOVE -1111111001111111111111111111111111 NMI INN 11111.1111111111111 MI DIRECT VENT HEATER j j - ° DRYER , r ' .... iIM ..... AMi€ FIREPLACE FRYOLATOR ____ -- "` FURNACE 1111111 11.1011111111111101111.1011111111011111111111111111111101111111101M1011111111111111 GENERATOR GRILLE 1i .. INFRARED HEATER ... ii ,a LABORATORY COCKS MIS Wit , MAKEUP AIR UNIT r 1 . . 1 OVEN I_ POOL HEATER ROOM/SPACE HEATER I 1 I ... .... WAR ROOF TOP UNIT Io ,a� TEST UNIT HEATER 1 1.111 UNVENTED ROOM HEATER WATER HEATER I OTHER ' I,. � . miraigliMillillillitilliell11.1111111,1 Ili.MI NOE MI . 1 I R 1 . ,k '. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Ej NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY-Fa - - QTHFR TYPE INDEMNITY- I] — 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. CHECK ONE ONLY: OWNER D 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 complianc a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4-- ...r/....— PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE#h2298 I SIGNATURE MP Lj MGF Lj JP JGF Lj LPGI 0 CORPORATION 0# 3281C PARTNERSHIP # :LC # COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING 1 ADDRESS 8 REARDON CIRCLE ,, CITY SOUTH YARMOUTH STATE MA i ZIP 102664 TEL 508-394-7778 FAX 508-394-8256 I CELL NIA EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts 'r. " � Department oflndustrialAccidents .�.,_ �,t� Office of Investigations —'� Lafayette City Center veztrar ;/% 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. 0 Retail 2.0 or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 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. 0 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.] 12.0 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. #2019AExpiration 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 ' 7 the ins and penalties of perjury that the information provided above is true and correct. Signature: -� .4...,.(..�- 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): 10Board of Health 2.0 Building Department 3.D City/Town Clerk 4.El Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia