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HomeMy WebLinkAboutBLDG-23-000820 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH ' MA DATE (August 16,2022 PERMIT# BLDG-23-000820 JOBSITE ADDRESS 161 WOLFSON RD I OWNER'S NAME IVESPA MARJORIE A G OWNER ADDRESS 161 WOLFSON RD SOUTH YARMOUTH MA 02664-1345 I TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL III 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 GENERATOR 1 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 ❑ 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 SIGNATURE MP© MGF ❑ JP El JGF CI LPG( ❑ CORPORATION 0#I I PARTNERSHIP 0#I IC ❑#ICOMPANY NAME: ISTEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH 'STATE IMA I ZIP '026641207 I TEL I FAX I )CELL EMAIL Iinspections(a.efwinslow.com . , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FIT`r=.4w= iT FITTING WORK --:Vim CITY YARMOUTH =� MA DATE[8/5/22 (PERMIT# JOBSITE ADDRESS 61 WOLFSON RD S YARMOUTH MA 02664 I OWNER'S NAME JOHN DOUCET f G OWNER ADDRESS !SAME jj TE 7813928396 TYPE OR 1 PRINT OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION:JD REPLACEMENT: El PLANS SUBMITTED: YES El NO[ APPLIANCES 7 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOOSTER '_ . . L_ _. . _ , 1 ._ CONVERSION BURNER COOK STOVE l_ _mKK l :f DIRECT VENT HEATER a_ DRYER FIREPLACEIIIIIINIIIITJJIMIFIIIIIIFIIMFIIIWIIIIIIIIIIII � I I II I FRYOLATOR Ns gmni FURNACE MI Nal GENERATOR I , _ GRILLE f 1 ' l i unn• INFRARED HEATER LABORATORY COCKS , MAKEUP AIR UNIT i OVEN POOL HEATER i E ROOM/SPACE HEATER 'Mann _ RIIIIFINIFICIFINffillitillrill i_ ROOF TOP UNIT TEST airr 1 € UNIT HEATER ' UNVENTED ROOM HEATER I I WATER HEATER �_ I �I__a _ 1 [OTHER I _... wm I_ i I ' l lti •1 ,_______ _ _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 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 t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian a P dine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4-11 PLUMBER-GASFITTER NAME STEPHEN WINSLOW '' LICENSE# 12298 .� SIGNATURE s1' MP MGF JP JGF LPG( CORPORATION #]3281C 1 PARTNERSHIPU# LC `� COMPANY NAME:1 E.F.WINSLOW PLUMBING&HEATING I ADDRESS 18 REARDON CIRCLE ,� CITY 'SOUTH YARMOUTH j STATE' MA J ZIP'02664 TEL 1508-394-7778 FAX!508-394-8256 -CELLI N/A IEMAILI INSPECTIONS@EFWINSLOW.COM 1 g s- r The Commonwealth of Massachusetts • �_ Department of Industrial Accidents w�. 19 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. ❑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. ; 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]** 11.0Health 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: 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§25Aof 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 perjuiy that the information provided above is true and correct. Signature: 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 30 City/Town Clerk 4.ElLicensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia