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BLDG-21-002064 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4,) CITY YARMOUTH MA DATE October 19,2020 PERMIT# BLDG-21-002064 is JOBSITE ADDRESS 24 OLD CASTLE RD OWNER'S NAME LYONS CAROLYN COX G OWNER ADDRESS C/O CAROLYN LYONS SARTORY ONE PLEASANT STREET COURT CHARLESTOWN TEL MA 02129 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ 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 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 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❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsAefwinslow.com --_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Eh , CITY __. _ _ __ __ _ ..___ _.__ m. MA DATE PERMIT# (.b -ZI-> 2b JOBSITE ADDRESS U 00l ��h 72 OWNER'S NAME G t�2( )5 OWNER ADDRESS [—A�----_ - ... _-.�.._, . . v_, TYPE OR ,_ , .,._. I TE 5 . V3 -FAX _ F.J PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL e�u ^ CLEARLY NEW,���� RENOVATION;�f REPLACEMENT:r � � RESIDENTIAL�„��� APPLIANCES 1 FLOORS-0PLANS SUBMITTED: YES n Np1_,, BOILER 6 �_ 10 11 12 13 14 ©Q 4 9 BOOSTERwitu t., "I= I ` COOK SIIIIIIIIIIIIIIIINIIIIIIIUNIMN CONVETOVE N BURNER ® I .. z ®� I I �, ® 1-�- III _--�I . ,_� DIRECTOOKVT HEATER 1„_ i I 1 _I (- DRYER —`-]I MI FIREPLACE I 1. 01- 11 kl _�,1 - 1 FRYOLATOR 1 I� i®:��1 FURNACEwoo MINimMJCL._�I GRILLE it ��iiiiiiiiiiiiillit ,I it�� - NMI INFRARED HEATERIllimilliti -` 71 LABORATORY COCKS I �,1 � �_ � h . � 5— I = [ �: MAKEUP AIR UNITVIINI F-_ _ir- I , rIV_w.F OVEN ' � 1 (. Th(- 4 :!� POOL HEATER _ ROOM I SPACE HEATER I { 11 I-_. 1 ,1 II �- ROOF TOP UNIT i .. 1 !. !..._ -_I( f'w bj ��- i III._- I- �i ._� irjUNIT HEATER =1 UNVENTED ROOM HEATER I-`a I d1 � WATER EATER I �_�n ® ®F I —1 I__ T i'I z OTHER - _,._, I --- 1 �T I :' li' Ti (---I I ®® MUM I '1 1 - , I( I___ I have a current lia bili Insurance policy or its substantialINSURANCE COVERAG ®^ I-`iiiiniii - ' �I n"1 1 I----I -- equivalent which meets the requirements of MGL.Ch.142 YES [+_,i NO � .. I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [y+_;l OTHER TYPE INDEMNITY El OWNER'S INSURANCE WAIVER:I am aware that the licensee does not OND the insurance coverage required by Chapter ter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. c� SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurat to the I � AGENT g? and that all plumbing work and installations performed under the permit issued for this application will be in c P rti r` Massachusetts State Plumbing Code and Chapter 142 of the General Laws, b st of my knowledge h complianc ��,� ne provision of the VS PLUMBER-GASFITTER NAME STEPHE N LOW _ _ LICENSE# 12298 MP !_' MGF[ JP JGF LPG' -- SIGNATURE CORPORATION Et,# 3281C PARTNERSHIP # LLC IC COMPANY NAME; E,FWINSLOW PLUMBING&HEATING `: ADDRESS 8 REARDON CIRCLE ------ `� CITY I SOUTH YARMOUTH � ��-��--� ``J --- -- - ---- STATE[MA ZIP 02664 FAX 508-394...iii —CELL N/A TEL 508-394 7778 i EMAIL INSPECTIONS a©EFWINSLOW,COM le Slit_ (eb The Commonwe, lth of Massachusetts Department of'ndustrial Accidents ' = ' = Office of nvestigations ram aml, Lafayett City Center UMW 2Avenue de Lafayette a Boston, MA 02111-1750 Af INV www. ass.gov/dia Workers' Compensation Insu ance Affidavit: General Businesses Applicant Information Please Print Le ibl Business/Organization Name: E.F. WINSLOW PL MBING & 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 90 employees (full anti/ 5. ❑ Retail or part-time).* 6. [ Restaurant/Bar/Eating Establishment 2. I am a sole proprietor or partnership and have no Office7 ❑ 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 ha e no employees. [No workers' comp. insurance required]** 10 []Manufacturing 4.❑ We are a non-profit organization, staffed by volunte:rs, 11•❑Health Care with no employees. [No workers' comp. insurance r:q.] 12.0 Other *My applicant that checks box#1 must also fill out the section below show ng their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation h.s 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 nsurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURAN l E COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. #1909A Expiration Date: 01/01/2021 Attach a copy of the workers' compensation policy decla ation 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 to $250.00 a day against the violator. Be advised that a copy o this statement may be forwarded to the Office of Investigatiiionspof the DIA for insurance coverage verification. I do hereby ter eJ the ins and penalties of perjur that the information provided above is true and correct. Si: ature: y Date: 01/02/2020 Phone#: 508-394-7778 Official use only. Do not write in this area,to be compl,ted by city or town official. City or Town: Issuing Authority(check one): Permit/License # 10Board of Health 2.0 Building Department 3.11 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.[]Other Contact Person: Phone#: mace vnv/(lia