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Home My WebLink AboutBLDG-23-000850 The Commonwealth of Massachusetts Department of Industrial Accidents x Office of Investigations ,� W •.' Lafayette City Center Ajar < 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 99 employees (full and/ 5. ❑ Retail or part-time.* _- — - __ 6. ❑Restauranti/Bar7Eating Establishment 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. 7• ❑ Office and/or Sales(incl.real estate,auto,etc.) [No workers' comp. insurance required] 8. 0 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]** 4.❑ We 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:01/01/2023 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 • er the ins an d penalties of perjury that the information provided above is true and correct. Signature: 7' ••.-- Date: 12/01/2021 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.❑Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �1= e� CITY YARMOUTH MA DATE August 17,2022 PERMIT# BLDG-23-000850 JOBSITE ADDRESS 18 LANSING LN OWNER'S NAME MCPHEE G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT 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 _ 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 0 OTHER OF INDEMNITY 0 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 Q MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsanefwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK VtE=v" CITY YARMOUTH I MA DATE 8/12/22 PERMIT# Z3— O?5O JOBSITE ADDRESS 18 LANSING LANE OWNER'S NAME MCPHEE/WADE RESIDENCE GOWNER ADDRESS SAME___w 1 TE 508-385-2704 iFAX _. TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL ,.... RESIDENTIAL UA PRINT CLEARLY NEW:LiRENOVATION: REPLACEMENT: PLANS SUBMITTED: YES[ NO APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER � m... .. ., 7 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER wwiserwmassiiirmosimmilalillinallWallillit FIREPLACE FRYOLATOR FURNACE MN ansonsmamaismommaismmostrimmusmi GENERATOR MN MM.isitimmiiestaimmilimusio No man GRILLE IIIIIFOIWIIIIIIIIMIIIIIIIIIIMIWIIMIOIWIMIIIIIIIIWAINMIKIMIIIIIO INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT11161 OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER_ IIIIIIIIIMIIIIIIIIIIIIIIIIIWIIIIIMIMIIIIIIIIIIIMIIIROIOIIIIIMIIIIIIIIEIIIIR OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES EA NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 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 Ej 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 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 complian Martine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �ii// • li/.�- y - PLUMBER-GASFITTER NAME'SSTTEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP MGFLJ JP'__ JGF Pi LPGI L CORPORATION #13281C PARTNERSHIP # LLC # -33 COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 18 REARDON CIRCLE .3333 CITY ,SOUTH YARMOUTH STATE MAj ZIP 02664 TEL i 508-394-7778 FAX[508 394-8256 1 CELL N/A 'EMAIL!INSPECTIONS@EFWINSLOW.COM 1