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HomeMy WebLinkAboutBLDG-23-002458 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •' CITY YARMOUTH MA DATE November 03,202; PERMIT# BLDG-23-002458 li JOBSITE ADDRESS 12 WAGTAIL LN OWNERS NAME DESKA RICHARD J G OWNER ADDRESS DESKA CATHERINE A 37 MONROE ST CHICOPEE MA 01020 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 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❑ 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 ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsna efwinslow.com j\, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK T=Shin=Ci �` CITY WEST YARMOUTH _ 23 - 21 51 '=".� ,,, MA DATE 11/3/22 PERMIT# JOBSITE ADDRESS 12 WAGTAIL LANE OWNER'S NAME CATHERINE DESKA GOWNER ADDRESS 1 SAME TEL 413-519-5159 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:D REPLACEMENT:J PLANS SUBMITTED: YES Li NO APPLIANCES 7 FLOORS—• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER II . C NMI MIM Oil NM Miff IMO BOOSTER CONVERSION BURNER t COOK STOVE . ... _ ... .... M[ aim iiiiiimim aim siii 11111 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 61.140.1111116.lialliniii riumitiliarilimelliiiirlaitiliMiiii=rig raZiamillinal GENERATOR £OROK MI 1111.11111111' GRILLE MOOMEMINI11011110•1111.11111.1.111111111r111111.1r WW1 INFRARED HEATER Mall ill NIIIICMIMIMFMIIISI.PMIIMIIIIIIIItllmMINili LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 11 .1111111MilitiMICION.MallM ROOM/SPACE HEATER 1111101111111111111111 11101111111.1111 MI MI MI MI NM In iiiiii iiii ROOF TOP UNIT TEST r ,Ma= UNIT HEATER FM ant imam an anitiiii UNVENTED ROOM HEATER i ,iii WATER HEATER WitS111111110111111.11111111.W.MONIM1111111111 MI all OTHER !NOSIMIfillittliall1.1101111.1111111111MOMMI1 MO Nig OM 0110111111111. I ... roIMINIFINIIIMOMOIMIIIIIMMITIIIIIII MOMMini IMO Iw. i INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO Lj I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY J OTHER TYPE INDEMNITY U 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 D AGENT 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 compliancnc ajl'PP rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i1 • `/ PLUMBER-GASFITTER NAME[STEPHEN WINSLOW LICENSE# 12298 i SIGNATURE MP LJ MGF Li JP Ej JGF LI LPGI 0 CORPORATION 0#L3281C I PARTNERSHIP[j# LLC #___ COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY LSOUTH YARMOUTH . STATE MA ZIP 02664 JTEL[508-394-7778 1 FAX 50,8-394-8256 1 CELLIN/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations lisp' Lafayette City Center Vier 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. [J 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.] 12.0 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. #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 fme 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 fme 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 the ins and penalties of perjury that the information provided above is true and correct. Signature: 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