The URL can be used to link to this page

Home My WebLink AboutBLDP-22-006945 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r• �' CITY YARMOUTH MA DATE June 01,2022 PERMIT# BLDP-22-006945 tl JOBSITE ADDRESS 166 MAYFLOWER TERR I OWNER'S NAME Chris Speers G OWNER ADDRESS 66 MAYFLOWER TER SOUTH YARMOUTH MA 02664-1117 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED:YES 0 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 2 MGF 0 JP❑ JGF 0 LPG( 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ISTEPHEN A WINSLOW ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH STATE MA ZIP 1026641207 TEL I 1 FAX 1 I CELL 1 EMAIL inspections(cilefwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK "7,g CITY YARMOUTH I MA DATE 5/24/22 I PERMIT# JOBSITE ADDRESS 66 MAYFLOWER TERRACE S YARMOUTH I OWNER'S NAME CHRIS SPEERS POWNER ADDRESS 651 EAST 14TH ST APT 3-D NEW YORK NY 10009 I TEL15083988739 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL ID EDUCATIONAL D RESIDENTIAL PRINT PLANS SUBMITTED: YES 0 NOLJ CLEARLY NEW: RENOVATION: REPLACEMENT:Ej FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE .__ DEDICATED SPECIAL WASTE SYSTEM I il _ I . I DEDICATED GREASE SYSTEM 1 DEDICATED GRAY WATER SYSTEM i _-_ �_ .',. __ . v__._ DEDICATED WATER RECYCLE SYSTEM _ „„_7,,,, i , I , a DISHWASHER 1 DRINKING FOUNTAIN 'FOOD DISPOSER I 1 FLOOR/AREA DRAIN i INTERCEPTOR(INTERIOR) KITCHEN SINK -` __ LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET i— � URINAL WASHING MACHINE RRRRRRRRRRRRRa WATER HEATER ALL TYPES 1 WATER PIPING ______ _ ._ ! 1' c I ',f OTHER m_ I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO CI IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I OTHER TYPE OF INDEMNITY ® BOND Ej 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 ® AGENT El 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 e to the b t of my knowledge O and that all plumbing work and installations performed under the permit issued for this application will be in co li wit II ertine proxisioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,.,i. �841,!/M_ PLUMBER'S NAME 1 STEPHEN WINSLOW I LICENSE#112298 I SIGNATURE MPO JP® CORPORATIONO#I3281C PARTNERSHIP®# ILLC®# _ COMPANY NAME' E.F.WINSLOW PLUMBING&HEATING I ADDRESS'8 REARDON CIRCLE 1 v' CITY'SOUTH YARMOUTH I STATE MA ZIP 102664 1 TEL 1508-394-7778 FAX 1508-394-8256 1 CELL`NIA 1 EMAIL I INSPECTIONS@EFWINSLOW.COM 1 7s1—At..4N. The Commonwealth of Massachusetts -- , f) Department of Industrial Accidents _'; `� Office of Investigations 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 90 employees (full and/ 5. El 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. ❑Non-profit 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]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.❑ 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: City/State/Zip: Policy#or Self-ins. Lic. #1964A Expiration Date:01/01/2022 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 ' the ins and penalties of perjury that the information provided above is true and correct Signature: Y '` -...." Date: 01/02/2021 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.OLicensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia