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HomeMy WebLinkAboutBLDG-22-05837 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e' CITY IYARMOUTH MA DATE 'April 12,2022 PERMIT# BLDG-22-005837 JOBSITE ADDRESS 1420 LONG POND DR OWNER'S NAME (HAY SANDRA K G OWNER ADDRESS 'PENDLETON PAMELA F 48 CHURCH ST HOLLISTON MA 01746 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ElRESIDENTIAL CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 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 0 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 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 I LICENSE# 112298 SIGNATURE MP© MGF ❑ JP 0 JGF 0 LPG' 12 CORPORATION 0#I I PARTNERSHIP 0#I ILLC ❑#I COMPANY NAME: ISTEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR, I CITY IS YARMOUTH I STATE MA ZIP 1026641207 I TEL I FAX I I CELL 1 I EMAIL Iinspections(c lefwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '_ '1= CITY YARMOUTH I MA DATE 4/1/22 I PERMIT# 2-1— 5 3 s` JOBSITE ADDRESS 420 LONG POND RD S,YARMOUTH 02664 I OWNER'S NAME PAM PENDLETON I GOWNER ADDRESS SAME I TEL 5088138115 IFAX TPRINOTR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL ID CLEARLY NEW: RENOVATION:El REPLACEMENT:D PLANS SUBMITTED: YES 0 NO Li APPLIANCES 7 FLOORS-4 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 FIREPLACEFRY f I OLATO. f 1GENERATOR ,, MAKEUPGRILLE INFRARED HEATER AIR UNIT �..__ IIIIIFI IIIIFIIIIIF POOL HEATER ROOM � � O •' UNIT TEST 1 UNVENTED ROOM HEATER WATER HEATER 1 1 ' OTHERC -. .. .I . ar I ,11a INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY . 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ® AGENT ED I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurst to the t of my knowledge tcs and that all plumbing work and installations performed under the permit issued for this application will be in complian a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME I STEPHEN WINSLOW I LICENSE#1 12298 I SIGNATURE 4) MP Ej MGF Ej JP Ej JGF EJ LPG'® CORPORATION D#13281C 'PARTNERSHIP D#I I LLC®# N ^' COMPANY NAME:I E.F.WINSLOW PLUMBING&HEATING I ADDRESS 18 REARDON CIRCLE I v$ CITY I SOUTH YARMOUTH 1 STATE I MA JZIPI 02664 ITEL 1508-394-7778 FAX 1 508 394 8256 I CELL N/A I (EMAIL;INSPECTIONS@EFWINSLOW.COM a nr,) The Commonwealth of Massachusetts r 9� _ 1 Department of Industrial Accidents i.: 4....*,r Office of Investigations Lafayette City Center 1=1111,0111•1111 4.:;w 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): 1.0 I am a employer with 90 employees (full and/ 5. 0 Retail or part-tune) *__-- 6. 0 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. 0 Entertainment their right of exemption per c. 152, §1(4), and we have no employees. [No workers' comp. insurance required]** 10.❑Manufacturing 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. #1964AExpiration Date:01/01/2022 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 • 7 the ins and penalties o f perjury that the information provided above is true and correct. Signature: -, ,..... 01/02/2021 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.D City/Town Clerk 4.[Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia