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HomeMy WebLinkAboutBLDG-23-001474 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 9'g. CITY IYARMOUTH MA DATE September 20,202 PERMIT# BLDG-23-001474 JOBSITE ADDRESS 150 JOYCE ST OWNER'S NAME (WELCH MARY E G OWNER ADDRESS 2302 PINEWOOD DR SMITHFIELD RI 02917 TEL' TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 1 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 plumping 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# 112298 SIGNATURE MP© MGF ❑JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#1 COMPANY NAME: ISTEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH STATE MA ZIP 1026641207 I TEL I FAX I CELL 1 EMAIL Iinspectionsna.efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK :':�'•J V CITY YARMOUTH 3 - IL/7 MA DATE 9114122 PERMIT# Z JOBSITE ADDRESS'50 JOYCE STREET SOUTH YARMOUTIT-1 OWNER'S NAME MARY WELCH .----J GOWNER ADDRESS SAME TELF 508 394 4249 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT Li RESIDENTIAL Li CLEARLY NEW:Li RENOVATION:ID REPLACEMENT: PLANS SUBMITTED: YES U NO, J APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER UM NMI _ 111111111111111 Illinillair OM NM', : ;: BOOSTER NMI I I : I .. 1 MOM. CONVERSION BURNER M COOK STOVE all avorimiiiiimini IITIIIIIIIIIIIIIIIIFIINIIIIIIIIIMIIF NM NM SIM NMI DIRECT VENT HEATER 1111.11.1.1M1111Wimmimarminit nit, Am sorimini DRYER FIREPLACEam FRYOLATOR , 1 1,_ , FURNACE J GENERATOR MI TOW GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ail lawintirlim 011111.11101110111111.1iiii aim Om mil _E ROOM/SPACE HEATER ' 1 I [F i ROOF TOP UNIT . R TEST .... .....• I UNIT HEATER I UNVENTED ROOM HEATER • _ ' WATER HEATER OTHER I OM I NMI 01111101111111111.11111111111111011.0111.11111111110101 Mfr.NM MN 11111111111 iir INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES EJ NO J I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE.POLICY IE OTHER TYPE INDEMNITY BOND U 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 Ei 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 complianc a rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 i SIGNATURE MP D MGF D JP Li JGF D LPGI D CORPORATION 0#I3281C 1PARTNERSHIP 0# LLC pit' COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATEr MA j ZIP 02664 JTEL 508-394-7778 FAX 508 394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW"COM The Commonwealth of Massachusetts ' Department of Industrial Accidents Office of Investigations a sair Lafayette City Center 1113.11111 t 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.ElI am a employer with 99 employees (full and/ 5. ❑Retail or part-time) 6. Restaurant/Bar/Eating EstablMtnent- 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 my 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.❑ Other *Any applicant that checks box 41 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 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 ce • el the phins and penalties of perjury that the information provided above is true and correct Signature: ,�/ Y'4. /••. ' Date: 12/01/2021 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): 1.1:Board of Health 2.1=1 Building Department 3.1:City/Town Clerk 4.1:1Licensing Board 5.1:Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia