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HomeMy WebLinkAboutBLDG-22-004235 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK c� CITY 'YARMOUTH MA DATE 'January 28,2022 PERMIT# BLDG-22-004235 I JOBSITE ADDRESS 118 VACATION LN OWNER'S NAME 'Edward Shea G OWNER ADDRESS 118 VACATION LN WEST YARMOUTH MA 02673 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL ID CLEARLY NEW: ❑ 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 1 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 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 0 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 I LICENSE# 112298 I SIGN MP© MGF 0 JP 0 JGF❑ LPG' 12 CORPORATION 0#I I PARTNERSHIP 0# ILLCRE COMPANY NAME: ISTEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR, CITY IS YARMOUTH I STATE IMA I ZIP 1026641207 I TEL I FAX I I CELL I I EMAIL Iinspectionsna,efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _E CITY [YARMOUTH w MA DATE 1/19/21 PERMIT# 21``IZ 3 f JOBSITE ADDRESS 18 VACATION LANE W YARMOUTH 02673 I OWNER'S NAME EDWARD SHEA GOWNER ADDRESS SAME I I TEL 5087286145 FAX L_4__ TYPE OR ., ..,� ,..___. I PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Ej RESIDENTIAL CLEARLY NEW: Ell REPLACEMENT:0 PLANS SUBMITTED: YES No[ APPLIANCES 1 FLOORS—� BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ' ', _ _�_ __.�._ ._.��� --_ BOOSTER ' _ '._ __._ . I An- I CONVERSION BURNER COOK STOVE �I s I _ _ � �. _ . I DIRECT VENT HEATER � -- DRYER FIREPLACE _ FRYOLATOR FURNACE GENERATOR ! r €._ T_ 4 _ _ jar ___ __._ GRILLE �_ ._ _ ' INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT iniimmy at _ OVEN Ran , POOL HEATER .._ ,_ mmun ROOM/SPACE HEATER TEST _..__ nROOF TOP UNIT ninon nwn � UNIT HEATER ! I I UNVENTED ROOM HEATER WATER HEATER. i l OTHER - • I_. _ 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 El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ED 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 CHECK ONE ONLY: OWNER AGENT ED r- 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. (--� o , PLUMBER-GASFITTER NAME I STEPHEN WINSLOW I LICENSE#I 12298 I � rSIGNATURE `,) MP MGF EI JP ID JGF® LPG'0 CORPORATION Ej#1 3281C I PARTNERSHIP Elk m. COMPANY NAME:I E.F.WINSLOW PLUMBING&HEATING I ADDRESS 18 REARDON CIRCLE CITY I SOUTH YARMOUTH 1 STATE I MA IZIPI 02664 ITEL 508-394-7778 I I FAXI 508-394-8256 I CELLI N/A JEMAILI INSPECTIONS@EFWINSLOW.COM I ', _ The Commonwealth of Massachusetts �.. aa_ Department of Industrial Accidents �� t Office of Investigations =ems= -t\ —.WORIMMIt.— 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. ❑Retail or part-time).* _ 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. El 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 10.1-1 Manufacturing no employees. [No workers' comp. insurance required]** 4.ElWe are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.❑ 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: 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 d 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 ' eT the ins and penalties of perjury that the information provided above is true and correct. . // Signature: '� ,...•!•r- 01/02/2021 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 3.0 City/Town Clerk 4.El Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia