The URL can be used to link to this page

Home My WebLink AboutBLDG-23-002047 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE October 17,2022 PERMIT# BLDG-23-002047 II ma JOBSITE ADDRESS 76 EILEEN ST OWNERS NAME MALZONE LOUTS F JR G OWNER ADDRESS C/O HOPPEN COURTNEY L 76 EILEEN ST YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 1 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ 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 0 MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(a),efwinslow.com F ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK fw Fi'� -a CITY YARMOUTH MA DATE 10110122, �"-_ / PERMIT# 2-`� •- 26(1r7 JOBSITE ADDRESS Lii EILEEN STREET OWNER'S NAME KEVIN HOPPEN G OWNER ADDRESS SAME TEL 774 238 6188 _. . FAX _ 4-1 TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL LiEDUCATIONAL Li RESIDENTIAL La CLEARLY NEW:Ll RENOVATION:EJ REPLACEMENT:Ld PLANS SUBMITTED: YES[I NO E APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER , BOOSTER CONVERSION BURNER am rimI COOK STOVE $., _. E DIRECT VENT HEATER f I .MR _ _ MN am mourimr NMI DRYER FIREPLACE .. ._; m: FRYOLATOR I --imiimmitmonaff nit FURNACE GENERATOR INNIMIM IIIIIIIII IIIIIIII NMI IIIIIIIIM IIII IIIII 11111 INN NOM OINK F_. GRILLE INFRARED HEATER LABORATORY COCKS oar INNI INNUININIIIIIIIINI MAKEUP AIR UNIT 6 WWII. F 3 INN OVEN liorlimmiim mom am----- sitailumirmo-m, wit ma POOL HEATER ROOM I SPACE HEATER i AN ROOF TOP UNIT E V . .... TEST 1.111 , am mar ins MINIIMIM. UNIT HEATER aismaii Imams oursulmostair OK SIR MIN } UNVENTED ROOM HEATER AM IIIIIIIM WI- i I I WATER HEATER _.. .. MINI MINI JIM: OTHER . f IIIIiIUIIIIiIIIIIIiIIIIIVVIIIIIIIIIIII�MIIIpIIIlllllllllllllllllll�ll�lllllll IIIIII . . am an no am INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LI NO U I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [E OTHER TYPE INDEMNITY 0 BOND Ej 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 LI 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 e�RfiF ay�P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /)i1 `i/.�- y PLUMBER-GASFITTER NAME[STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP Un MGF[ JP 0 JGF Li LPGI Lj CORPORATION 0# 3281C PARTNERSHIP _. # -I LLC[J#.r COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY I SOUTH YARMOUTH STATE MA ZIP 02664 ]TEL 508-394-7778 FAX[508-394-8256 I CELLIA_ jEMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts d� z_ilit=JJ//''((�)�y', Department of Industrial Accidents ;AIs1= Office of Investigations ' Lafayette City Center 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. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. employees working for me in any capacity. ❑Office and/or Sales(incl.real estate,auto,etc.) [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.❑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:01/01/2023 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 TOf 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. j Signature: ` ` R— /....v. 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.❑City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#• www.mass.gov/dia