Loading...
HomeMy WebLinkAboutBLDP-21-002655 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t t _-= CITY IYARMOUTH MA DATE (November 10,202( PERMIT# BLDP-21-002655 JOBSITE ADDRESS 142 DEBS HILL RD UNIT 3A OWNER'S NAME ICAMPANE ROSEMARY ANN G OWNER ADDRESS 42 DEBS HILL RD YARMOUTH PORT MA 02675 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO 0 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/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❑ 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 Lereby 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 d that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the ssachusetts State Plumbing Code and Chapter 142 of the General Laws. UMBERGASFITTER NAME 'Stephen Winslow© MGF LICENSE# 12298 SIGNATURE ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLCMPANY NAME: STEPHEN A WINSLOW ❑#��ADDRESS. 8 REARDON CIR, Y S YARMOUTHSTATE MA ZIP 026641207 TEL CELL EMAIL inspections@efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -E1�', CITY YARMOUTH q� ��yy,, , , �.. . ...,...a�n. MA DATE 10/27/20 PERMIT# ��P-Z1-'W JOBSITE ADDRESS 42 DEBS HILL ROAD OWNER'S NAME CAMPANE G OWNER ADDRESS _ TEL508.394.4065 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT E EDUCATIONAL 0 RESIDENTIAL CLEARLY NEW: RENOVATION:Li REPLACEMENT: EA PLANS SUBMITTED: YES Lj NO if I APPLIANCES 1 FLOORS—. BSM i 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER 4 I i DIRECT VENT HEATER intillatiMmitlialimmurilliMinitintamilimialtim DRYER FIREPLACE FRYOLATOR FURNACE : GRILLE INFRARED HEATER LABORATORY COCKS 1- all MK POOL HEATER , 1... 11M1111111.1111111.11111111NOMINIMISIIIMINII gm ROOM/SPACE HEATER - . ROOF TOP UNIT I TEST .orlairMwormiamiliantantami SIX I UNVENTED ROOM HEATER UNIT HEATER 011111111111111111111111.1111111.0airsitManiwremtammo"woo i animini imam alsing ow ow MO 539088 r' �� ° INSURANCE COVERAGE . I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO Li I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ll,j 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. 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 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 PP rtine Massachusetts State Plumbing Code and Chapter 142 of the General Laws. tom/ R-• provis/ion of the PLUMBER GASFITTER NAME STEPHEN WINSLOW ` __ _ ;LICENSE#(12298 SIGNATURE MP r!J MGF Li YJP L JGF 0 LPGIni CORPORATION 0# 3281C PARTNERSHIP # LLC # COMPANY NAME E.F.WINSLOW PLUMBING&HEATING __ __ L_:f._ I ADDRESS r 8 REARDON CIRCLE CITY SOUTH YARMOUTH _� as �u__' ' STATE MA I ZIPS 02664 TEL 508 398-7778 CELL FAX 508 394 8256--#� N/A EMAIL I 508- NSPECTIONS@ EFWINSLOW.COM The Commonwealth of Massachusetts --- Department of Industrial Accidents w = G Office of Investigations =sf+��= Lafayette City Center -�4 _I'-= 2 Avenue de Lafayette, Boston, MA 02111-1750 -sap-- 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 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. ❑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]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 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. 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. #1909A Expiration Date:01/01/2021 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 • of the ins and penalties of perjury that the information provided above is true and correct. Signature: Y �f!-� -�h--- Date: 01/02/2020 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): LOBoard of Health 20 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia