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HomeMy WebLinkAboutBLDG-23-001523 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I CITY YARMOUTH MA DATE September 22,202 PERMIT# BLDG 23 001523 JOBSITE ADDRESS 1 WEST WOODS VILLAGE OWNER'S NAME anne mane qavin G OWNER ADDRESS 1 WEST WOODS YARMOUTH PORT MA 02675-1462 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 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 El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ BOND El 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 El JP❑ JGF El LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL r FAX CELL EMAIL inspectionsta7,efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK %. 1==e CITY YARMOUTH MA DATE_ F 9/19/22 PERMIT# 2q' I Y 73 JOBSITE ADDRESS 1 WEST WOODS CIRCLE OWNER'S NAME ANNMARIE GAVIN GOWNER ADDRESS SAME — -_____._ .. - �.____�.__ TE 508 737 1898 FAx��_.-_ TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL PRINT RESIDENTIAL Li CLEARLY NEW:LIRENOVATION:Li REPLACEMENT:.4 PLANS SUBMITTED: YES Ej NO`J APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 1 7_I 8 9 10 11 12 13 14 BOILERNM - i µ lI_I € BOOSTER ill 1111111ilir 1 CONVERSION BURNER , it 1110.111171111111.1 -- COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR _allirtiarallitralli.R.11111MMOIS MOM ON WON GRILLE r f INFRARED HEATER _(...- -.... . ....... 5 ... _. _. - I gym. LABORATORY COCKS imi MAKEUP AIR UNIT OVEN P' I POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST '4 misaisimi-. , UNIT HEATER UNVENTED ROOM HEATER - 0-- WATER HEATER OTHER _1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY al OTHER TYPE INDEMNITY L.j 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 AGENT 11 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 YPtertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �i/ • �i/�.- -. PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 J SIGNATURE MP n,!_ MGF I_ ...._..JP JGF _ .' ,.LPG! CORPORATION # 3281C _ PARTNERSHIP # ___ LLC 0# COMPANY NAME I E F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY ?SOUTH YARMOUTH V ,M MA_ m µ STATE ZIP 026 4 TELL.08-394-7778 FAX`508-394-8256 CELL N/A EMAIL fNSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts o Department of Industrial Accidents 111 ii, _1J, Office of Investigations Lafayette City Center kti � �a 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: 11 Business Type(required): —tf-t nr a employer-with -- employees (fall and 5,�1 Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.0 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. 0 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 *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#I. 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 undcr--25A of MGL c. 152 can lead tothe imposition ��Vi i.i lliliuul-pcllciltivJ Uf d 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 ceri the ins and penalties of perjury that the information provided above is true and correct. Signature: ?L. .. • 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): 1.0Board 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