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HomeMy WebLinkAboutBLDG-23-003247 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e '�,' CITY YARMOUTH MA DATE December 12,202; PERMIT# BLDG-23-003247 JOBSITE ADDRESS 902 ROUTE 28 OWNER'S NAME GERARDI DIEGO A G OWNER ADDRESS GERARDI SASHA A 17 BRIDLE PATH BREWSTER MA 02631 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 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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# 12298 SIGNATURE MP❑ MGF © JP 0 JGF❑ LPG' 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 02664 TEL 5083947778 FAX CELL EMAIL inspections(d),efwinslow.com . - -:, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 5' `=1F CITY I YARMOUTH 1 MA DATE 12/5/22 — PERMIT# �'- '5 TZ -1 JOBSITE ADDRESS 902 ROUTE 28 i OWNER'S NAME GERARDIS CAFE GOWNER ADDRESS SAME __1 TEL 508 394 3111 JFAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIALS+l EDUCATIONAL LA RESIDENTIAL CLEARLY NEW:Lj RENOVATION: REPLACEMENT:Ld PLANS SUBMITTED: YESED NO Li APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER aOM OM NM ON MN ....m.. 1.. .,_ 1 1 ...... SIM BOOSTER CONVERSION BURNER 1. COOK STOVEIIIIIIFIIIIIIFSIIIIIIIIIMIIIIIIIIMIIII . 1j_ DIRECT VENT HEATER IOW MOM 'Mt OMR OM Mr MN 1111111111111 mm DRYER FIREPLACE FRYOLATOR alliallf OM FURNACE _ ., GENERATOR 1 F 1' 1.1111111111101111111111111 101111111111111 OM MI all GRILLE INFRARED HEATER .1111101011111.11111011•111 MI,OM IIIIII SW MN 1111111111111t LABORATORY COCKS MAKEUP AIR UNIT 1111,11i 111.111101M Mit OW ? OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 111110-11.11111. 11 11.1111111 ON III IR _ UNIT HEATER �; ' miorwromintimonmwomic UNVENTED ROOM HEATER OK WIIIIIIIMON111111111.01-OM IMP MI NM 11111111111 11111 i MI WATER HEATER .. _ MAW MOM OM pm MN 011111111.1111111Nalitint 111111111.1111 OR 011 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE 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. CHECK ONE ONLY: OWNER 0 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 compliant a Pprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 71.f/ !/ _. _ __ �_ y -. PLUMBER-GASFITTER NAME LST_EPHEN WINSLOW LICENSE# 12298 SIGNATURE MP 0 MGF Li JP Li JGF 0 LPG LI CORPORATION l..+. # 3281C PARTNERSHIP 0#11 LLC 0#L COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING 71 ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 JTEL 508-394-7778 I FAX 508-394-8256 1 CELL N/A EMAIL INSPECTIONS@EFWINSLOW COM ........... The CTommonwealth of Massachusetts Department of Industrial Accidents ti ..ham Office of Investigations =a Lafayette City Center `� 1lif ; 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• 0 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. ❑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=yearimprisont-nent,as well as civil penalties in the form of a-S T OPWORK ORDER acid a fine bf 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 cer • of the ins and penalties of perjury that the information provided above is true and correct. Signature: 7Y /,...•l•...- 12/01/2021 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): 1.Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.DLicensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia