The URL can be used to link to this page

Home My WebLink AboutBLDG-23-002782 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK l e CITY 'YARMOUTH ( MA DATE (November 18,2024 PERMIT# BLDG-23-002782 JOBSITE ADDRESS 132 ALEXANDER DR I OWNER'S NAME IDWYER MARY V G OWNER ADDRESS IDWYER CAROLYN M 32 ALEXANDER DR YARMOUTH PORT MA 02675 I TEL I I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO❑ FIXTURES FLOORS-- BOILER BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOOSTER CONVERSION BURNER COOK STOVE 1 • DIRECT VENT HEATER • DRYER FIREPLACE FRYOLATOR FURNACE 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. IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW YES El NO❑ 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 MP 0 MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATIONL❑#SEMin SIGNATURE COMPANY NAME: STEPHEN A WINSLOW PARTNERSHIP 0# MN LLC El#� ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 02664 TEL 5083947778 FAX CELL EMAIL inspections(7p efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i®a 1.=iib1 4 CITY YARMOUTH MA DATE 11/14/22 PERMIT# 11—27 8 Z JOBSITE ADDRESS 32 ALEXANDER DRIVE OWNER'S NAME MARY DWYER GOWNER ADDRESS SAME . ......... TEL 508 367 6925 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT RESIDENTIAL CLEARLY NEW:Li RENOVATION:Li REPLACEMENT: „.! PLANS SUBMITTED: YES El NO LA APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER a BOOSTER �...... .,..w. CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER ' lif FIREPLACE -11111111.11. FRYOLATOR FURNACE GENERATOR ______111111111111111.111 111111111111 MI 111.111111 am an am am GRILLE Imirmirmintiowmaitioriersurairompor win" INFRARED HEATER LABORATORY COCKS IIMIIIIIIIIIIIIIIIIIIIINUIIIIIIIIMIIIIIOIIIIIIIIIIIIIIIIMIIIIIIIIIIIMIIBIIIIIIIIIMWIMIB MAKEUP AIR UNIT OVEN POOL HEATER _ IIIOIIIIIIIWIMMMF ROOM/SPACE HEATER _. _ ailframilimiiiill ROOF TOP UNIT TEST UNIT HEATER Mt wirmairommintimisominorimmormiiiiiis UNVENTED ROOM HEATER WATER HEATER OTHER wow minim rim[iiirlit imi sp.wing mg gip nig oil INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO Li I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej 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 Ej 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 complianc a Pertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,i/' ST PLUMBER-GASFITTER NAME EPHEN WINSLOW LICENSE# 12298 YSIGNATURE MP 0 MGF LJ JP JGF Ej LPGI CORPORATION # 3281C �PARTNERSHIP # µ LLC DIL COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH _ STATE MA ZIP 02664 TEL 508 394 7778 FAX 5 8 394-8256 i CELL N/A ................. __ EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts �— Department of Industrial Accidents — 1, _�=f Office of Investigations "(li, tt rrrr Lafayette City Center 2Avenue de Lafayette,Boston,MA 02111-1750 ■+,` sr 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): LEI I am a employer with 99 employees (full and/ 5. 0 Retail - - or rt time . b. aRest:aurarit/Bar/Eating Establishment _- 2.0 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. 0 Non-profit 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.IDWe are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.0 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. 1 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 cer ' e the ins and penalties of perjury that the information provided above is true and correct. Signature: /Y'�'` ....�"4 — 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): 1fBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia