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HomeMy WebLinkAboutBLDG-22-002989 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK n‘47,,t _ '' CITY YARMOUTH MA DATE November 23,2021 PERMIT# BLDG 22 002989 JOBSITE ADDRESS 15 MAKEPEACE LN OWNER'S NAME SINGLETON MARY E G OWNER ADDRESS 15 MAKEPEACE LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL EJ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 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© MGF 0 JP❑ JGF 0 LPGI 0 CORPORATION 0# _ PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(a)efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Y=<�1 's ffi--kl= " CITY YARMOUTH(WEST) I MA DATE'11/19/2021 —]PERMIT# 7-1--- Z5 P5 JOBSITE ADDRESS 15 MAKEPEACE LANE,W YARMOUTH,02673 OWNER'S NAME MARY SINGLETON J GOWNER ADDRESS [SAME j-JTEL7742510399 IFAX TYPE OCCUPANCY TYPE COMMERCIAL U EDUCATIONAL rj RESIDENTIAL CLEARLY NEW:0 RENOVATION:Li REPLACEMENT:ED PLANS SUBMITTED: YES 0 NOLD APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER {My Mt BOOSTER r _ MI L___ ,9 L-. 1 CONVERSION BURNER COOK STOVE .'' nu NE maw am immunuatimi ism on nu DIRECT VENT HEATER IOWS ,gym DRYER INNICM1111111M. amoicsiiminw 11111111.1111111111,MN OM FIREPLACE _ , ;_ FRYOLATOR 011.111011101011011111111111.1111101111111111111111111 MOM 11111111110111111111111111111111111.1 FURNACE MI. ; GRILLE INN _ 1 1 1, . J INFRARED HEATER 1111111 antiiiiiiimeEaili LABORATORY COCKS NM MI MN 11.1111111.1110111 MAKEUP AIR UNIT IliNiailMIMI OM 1.1011111111111111111,MI ausimorimiasommum OVEN I _.. . ,. . ..; POOL HEATER ,, A ROOM I SPACE HEATER am aftwima . ow Mil Mrallii-WM MI OM ROOF TOP UNIT TESTINN IMIIIIIIII.--M—IM E UNIT HEATER _ _ _ ...li IMMIIIIIIM UNVENTED ROOM HEATER WATER HEATER _ .. 1E OTHER INMI ,1 .. -. :�.. INFIIMMORIMINIII 1111111 OM NINAMMOINIIIIIIMMI INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO Ej I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L J OTHER TYPE INDEMNITY Li BOND El 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 U 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 accuratg 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 rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��`/ 71 •y —. .....,,,`/ L. PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298_ SIGNATURE MP izi MGF El JP 0 JGF D LPG!Li CORPORATION LP 3281C PARTNERSHIP EP J LLC # I ..__ COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE f CITY SOUTH YARMOUTH STATE r-MA .ZIP 02664 ---1TEL 508-394-7778 FAX 508-394-8256 CELL N/A ]EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 7a _= 1= Office of Investigations -- Lafayette City Center tifE='? _ 2 Avenue de Lafayette,Boston, MA 02111-1750 wwx.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: I Business Type(required): 1.L1 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, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. El 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.❑ Health Care 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§ 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 ' e the ins and penalties of perjury that the information provided above is true and correct. Signature: '- .•.mil•-- 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 2.1:3 Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia