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HomeMy WebLinkAboutBLDG-23-002395 ;4—2 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK PP • ri CITY YARMOUTH MA DATE November 01,202; PERMIT# BLDG-23-002395 - I i_' u" JOBSITE ADDRESS 5226 HEATHERWOOD OWNERS NAME SEWARD HELEN S OWNER ADDRESS 5226 HEATHERWOOD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© 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 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 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 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# 112298 I SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' 0 CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: ISTEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH I STATE MA ZIP 1026641207 TEL I FAX 1 CELL 1 EMAIL (inspectionsta7,efwinslow.com _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4II(—a CITY YARMOUTH PORT MA DATE 10/26/22 PERMIT# Z3 — Z 3 5— JOBSITE ADDRESS 5226 HEATHERWOOD DRIVE —I OWNER'S NAME HELEN SEWARD OWNER ADDRESS SAME TE 412-979-5948 FAX L TYPE OR OCCUPANCY TYPE COMMERCIAL; J PRINT EDUCATIONAL € RESIDENTIAL CLEARLY NEW: _ RENOVATION:i REPLACEMENT:IA PLANS SUBMITTED: YES NO Li APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER C..W...W. BOOSTER I... ....,.,_. .. ,..,.w _ sR. o- aallit CONVERSION BURNER Illt __ COOK STOVE .... P " DIRECT VENT HEATER sio = .' as 1 DRYER FIREPLACE FRYOLATOR ,.,. . ..._. FURNACE mg imi "ma GENERATOR u.., �,. I GRILLE d INFRARED HEATER �g li r A • LABORATORY COCKS _IIM i '.� MAKEUP AIR UNIT OVEN I E � 1: POOL HEATER ROOM I SPACE HEATER 1 [ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER __ r..,. 11mm # WATER HEATER OTHERS. niiiiisamon milmstiiiiiiwar ammir, intimation", aniimisiiimilw- I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LI NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY , OTHER TYPE INDEMNITY vn BOND �Wm, 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 CD AGENT El 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 i a PP rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • 4... PLUMBER-GASFITTER NAME riEf,,PHEN WINSLOW LICENSE# 12298 SIGNATURE MP 'al MGF JP 0 JGF 0 LPG'..._ CORPORATION j,.# 32816 PARTNERSHIP # I LLC 0# COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY 1 SOUTH YARMOUTH STATE�MA ZIP 02664 TEL i 508-394-7778 4 ........... FAX 1508-394-8256 CELL N/A 'EMAIL' NSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Md Department of Industrial Accidents t � l Office 1of Investigations leima ' Lafayette City Center t4 1. 2Avenue 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 -61❑"RestaurantiBar/Eating Estabhs " ent 2.❑ I am a sole proprietor or partnership and have no 7employees 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, 11.0 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 fine up to$1,500 10 and/or-one-year--imprisortment,as well as civil penalties in the form of a-STOP WORK ORDER anda 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 • er the ins 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): 1fBoard of Health 2.0 Building Department 30 City/Town Clerk 4.OLicensing Board 50 Selectmen's Office 6.[]Other Contact Person: Phone#• www.mass.gov/dia