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HomeMy WebLinkAboutBLDP-23-004205 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,� 1 CITY YARMOUTHkr, MA DATE January 30,2023 PERMIT# BLDP-23-004205 I ., JOBSITE ADDRESS 13 CARTER RD OWNER'S NAME Mark Fallon G OWNER ADDRESS 13 CARTER RD SOUTH YARMOUTH MA 02664-4405 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT CLEARLY NEW: 0 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 . 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 ❑ 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❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: 'STEPHEN A WINSLOW ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 02664 TEL 15083947778 FAX l CELL l EMAIL linsoectionseefwinslow.com 1.^ , f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,_uin�0 `�Ii CITY Yarmouth MA DATE 1/26/23 PERMIT# 23 — 4 /or edy JOBSITE ADDRESS 13 Carter Road 1 OWNER'S NAME Mark Fallen R E C E I V F ❑ GOWNER ADDRESS same 1 TEL 781-710-428 FAX 1111 TYPE OR JA `� • . .I .. PRINT OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL i RESIDEN.IA CLEARLY NEW:® RENOVATION: REPLACEMENT:� PLANS BMITTED YES P��ET APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER "M IMIIIII BOOSTER .. 1 ! f..,Milili f i 111111 CONVERSION BURNER 11.01,01111111/1WWWWWWWWWWW MOM COOK STOVE DIRECT VENT HEATER ; ��1 ] � ,�1 � �����SIM DRYER 3i FIREPLACE FRYOLATOR € ' 1 WI FURNACE WOW NM 1111111.111111 GENERATOR WOWI IMI11.1101111.MI MI miff WM tom all MIMI GRILLE I INFRARED HEATER f 'i .. . i MI .. LABORATORY COCKS WO WO WO IMIWOW WOW 111.1.MAIM .011111191111.11111111 . . . MAKEUP AIR UNIT Ij 1 i .. OVEN ; ��WOO______ . , , POOL HEATER ROOM/SPACE HEATER OW OW WOMOMOWWWWWMit ROOF TOP UNIT i I [ € Ii . TEST i. I W Mg UNIT HEATER y UNVENTED ROOM HEATER WIIMIWIM l WATER HEATER j IIIMINIOW WOW OTHER WII WIIMMINWIIM MOW IOW WWWWWW1W01 Wil .: .. [1111111.1111111111111.1111.1111 =minimmillim,==0.1.11111,rmirinsiiiallolirsamomiamilliffsollamiwwwwwwwww INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO Li I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY EA OTHER TYPE INDEMNITY Lj 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 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 complianc a Pprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .1 ` /./_.- y —� PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP J MGF Li JP Li JGF Li LPG!Ej CORPORATION 0# 3281C ` PARTNERSHIP LJ# LLC ,,, # COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH . STATE MA1ZIP 02664 TEL 508-394-7778 FAX[508-394-8256 CELLF N/A ___ EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents i i f Office of Investigations - .41-i Lafayette City Center f= 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): 1.0■ 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. 0 Office and/or Sales (incl. real estate, auto,etc.) employees working for me in any capacity. 8. Ei Non-profit [No workers' comp. insurance required] 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 4.0 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 ce ' e�the ins and penalties of perjury that the information provided above is true and correct. Signature: �' .f... ........� 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): i f:Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.0Licensing Board 5.0 Selectmen's Office 6.QOther Contact Person: Phone#: www.mass.gov/dia