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HomeMy WebLinkAboutBLDG-23-004206 -�,`, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK l CITY YARMOUTH‘4,,,,, MA DATE January 30,2023 PERMIT# BLDG-23-004206 JOBSITE ADDRESS 15 CAPT STANLEY RD OWNER'S NAME Robert Olsen • G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Ell PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 I 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 0 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. 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 0 MGF © JP 0 JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ISTEPHEN A WINSLOW ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH STATE MA ZIP 102664 TEL 15083947778 FAX I I CELL I I EMAIL Iinspections(a,efwinslow.com TM RECEIVED MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERF RM GAS FITTING W R is f-, CITY Yarmouth I MA DATE 1/26/223 I P RMIT# 2 2023 JOBSITE ADDRESS[15 Captain StanleyRoad DING DCPARTMENT P OWNER'S NAME Ro aI�en GOWNER ADDRESS same 1 TE 617-823-0217 -"FAX, TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW:[J RENOVATION:Li REPLACEMENT:Li PLANS SUBMITTED: YES ID NO LI APPLIANCES 2 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER [ r- CONVERSION BURNER all - 1 I 1. F COOK STOVE DIRECT VENT HEATER i, DRYER Mill WSW 1111".4 WI 1 1 f FIREPLACE MOM ail MK III IIIIIIIIII . FRYOLATOR ON MIMIIIIINIEIIMAIIIIIIINIIIIIIIIIIIIRIMIIIIIIIIIIIIIWI FURNACE II ' GENERATOR inn OM Mk ialliall.OMMI NW OK INFRARED HEATER 11 I _ i 1- , , n, , mg om MAKEUP AIR UNIT Mailitill ' 111.1111 OVEN 111111111 110011111WillitaliiilliarMi ? POOL HEATER NM MINI IIIIIIIIIMIIIII OM ROOM/SPACE HEATER 1 : ROOF TOP UNIT OltlinalnitlMMINI1 Mr llIMMLNI WINK TEST NMI l UNIT HEATER Mt 1111.111111111111111 MI MI E IIIIIIIIIIIMIIIIIIIIII UNVENTED ROOM HEATER IIINIMIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIII MIN WATER HEATER MIN 'II liiiialliaiiiiMillitimi ion, OTHER WilliOillii Sifliiiit iiiirailil alliailiMililliMall. a 1.1.111111111.111111111111.1111IIME SWIM E E INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LI 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 [J 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 ED 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 YPprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 71,f/ . `/ _ y -• .......- - PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 J SIGNATURE MP[LI MGF 0 JP Li JGF 0 LPGI u CORPORATION„ # 3281C PARTNERSHIP # ..NJ LLC A# COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH 0 STATE MA ZIP 2664 �-�TEL 508-394-7778 ... FAX 508-394-8256 1 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _w�! ' Lafayette City Center rj -- /Z. 2 Avenue de Lafayette, Boston,MA 02111-1750 e 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. ❑Nor-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]** 4.0 We are a non-profit organization, staffed by volunteers, 11.0Health Care 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 . the ins and penalties of perjury that the information provided above is true and correct. Signature: r '" 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 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia