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HomeMy WebLinkAboutBLDG-23-004067 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE January 24,2023 PERMIT# BLDP-23-004067 JOBSITE ADDRESS 82 SIERRA WAY OWNER'S NAME EBREO MICHAEL A G OWNER ADDRESS EBREO CAROL A 82 SIERRA WAY WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES El 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 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 El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY El 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 El MGF © JP El JGF El LPGI El CORPORATION❑# PARTNERSHIP El# LLC ❑# COMPANY NAME: ISTEPHEN A WINSLOW ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH STATE MA ZIP 02664 TEL 15083947778 FAX I CELL I EMAIL linspectionsanefwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I. yv-� i y�=tvi ,'- S-aim,,.� ......... ..... l W CITY LYarmouth I MA DATE 1/13/23 I PERMIT# 21 _ LI G(0-7 JOBSITE ADDRESS 82 Sierra Way —"OWNER'S NAME Michael Ebreo GOWNER ADDRESS [same I TEL 508-694-7864 1FAX � _ TPRINOTR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW:.40 RENOVATION:Li REPLACEMENT:LI PLANS SUBMITTED: YES[ NO Li APPLIANCES Z FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ' ' Imo . BOOSTER [ —IL I. ir —1. . [ r [ Oar MN CONVERSION BURNER ` . .m.T. _ :I. I II- COOK STOVE mg pm gm affiallomi aiii MM.gailigatimu Mg M.MK DIRECT VENT HEATER r woo man amisatimiminiiimionuarniilw DRYER ' FIREPLACE FRYOLATOR IVII111 lailii {° ' . g, ; FURNACE I I C GENERATOR L r i GRILLE NM 1111.11 NM NMI ant .en...... I / INFRARED HEATER 1.111.1111011111111111Mallaii MMI 1111111111111101111111111111_, ,. ._:- LABORATORY COCKS gm. pirmaigniargag as imi gm anummi mina mg gat MAKEUP AIR UNIT Mae 1111111111111111 11111111111111.1.NM . OVEN -��....J I 1 .ii I E POOL HEATER Nil i moo* t ROOM/SPACE HEATER r ROOF TOP UNIT IMMINIM TEST I ; UNIT HEATER : MIN MN UNVENTED ROOM HEATER I - WATER HEATER OTHER aR, � _ wI 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 El OTHER TYPE INDEMNITY Li BOND 0 OWNER'S INSURANCE WAIVER:Lam aware that the licensee does nothave the insurance coverage required hy__Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER J 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 ajtP rtine Provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1? -. .........1-.-- PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 J SIGNATURE MP 0 MGF,j JP 0 JGF 0 LPGI 0 CORPORATION LP 3281C PARTNERSHIP #x ,LLC D# COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS-8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE L MA i ZIP 02664 [TEL 508-394-7778 FAX 1 508-394-8256.j CELL N/A !EMAIL,INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents .. �rt=_ Office of Investigations -"�! �' Lafayette City Center */ 2 Avenue de Lafayette, Boston, MA 02111-1750 �` ww».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. ❑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.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ 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 ' 7 the ins and penalties of perjury that the information provided above is true and correct. Signature: 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): 1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia