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Home My WebLink AboutBLDG-23-002015 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' = - CITY YARMOUTH MA DATE October 14,2022 PERMIT# BLDG-23-002015 JOBSITE ADDRESS 62 QUARTERMASTER ROW OWNER'S NAME MIKULLITZ JOHN F G OWNER ADDRESS MIKULLITZ KELLY J 9 EDINBURGH DR EAST SCHODACK NY 12063 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT PLANS SUBMITTED: YES ❑ NO ❑ CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ 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 1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 ❑ 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# 112298 I SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑#I I PARTNERSHIP ❑#I ILLC ❑#1 ADDRESS. 18 REARDON CIR,8 REARDON CIR COMPANY NAME ISTEPHEN A WINSLOW I CITY IS YARMOUTH (STATE IMA I ZIP 1026641207 I TEL I I FAX I I CELL 1 !EMAIL Iinspections(a efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK wow/,- CITY [-YYARMOUTH 3 MA DATE 1016122 PERMIT# JOBSITE ADDRESS 62 QUARTER MASTER ROW OWNER'S NAME JOHN CARR GOWNER ADDRESS SAME TEI1 508-838-8331 FAX yy . TYPE OR OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL `_J RESIDENTIAL`' PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: ' PLANS SUBMITTED: YES 1 NO APPLIANCES 1. FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER L. ° PININ COOK STOVE ` marairosignignirom DIRECT VENT HEATER DRYER 1 FIREPLACE FRYOLATOR 1.11111111.11101111.0.11.11111.00.11110100/01 FURNACE ® , GENERATORINITINIMMINSININNIMISMNII UM GRILLE ___.„1111111111111111111111011101M.1101MIIMININNIMIN INN INFRARED HEATER 1.1111, _ LABORATORY COCKS MI ®®IMPINAINMININIMINIINIIMOMII NW MAKEUP AIR UNIT i' ,1 ANN - j OVEN �� l POOL HEATER 9. I� 6 I ROOM 1 SPACE HEATER I ROOF TOP UNIT _ ___ TEST MIMI 1111111111111.11M IININO1 UNIT HEATER ® . .. 11111111111111r NM_��- NI UNVENTED ROOM HEATER INNIIIIIIIIIIIIIIINIMINIMII _IIII® '. WATER HEATIPMMINIM ER. __� �_._ _ NIMINIIOTHER 3 .1011111.11110 ___NINSINIMININNINININNININNIN INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY BOND Li 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 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. (. Y"_ ....1+-0- PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP ' MGF JP JGF i LPG' y CORPORATION #[3281C PARTNERSHIP # LLC # COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS1L„.8 REARDON CIRCLE ZIP 02664 TEL 508-394-7778 STATE MA�� CITY 1 SOUTH YARMOUTH � � — a. — 1 _ . FAX 508 394-8256 J CELLNIA_ EMAILFINSPECTIONS EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 9; .,'1----719 tr Office of Investigations t.. H Lafayette City Center 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 IAre you an employer? Check the appropriate box: I Business Type(required): 1.lit am a employer with 99 employees (full and/ 5• 0 Retail 2.Oor part-time).* 6. O Restaurant/Bar/Eating Establishment I am a sole proprietor or partnership and have no 2 ❑Office anc, , say s(incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.0 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. 10.0 Manufacturing [No workers' comp. insurance required]** 4.0 We are a non-profit organization, staffed by volunteers, 11. 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 01/01/2023 Expiration Date: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 criminal 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 uppto $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 ' 7 the ins and penalties of perjury that the information provided above is true and correct. Signature: Y "` /....../..-r- 12/01/2021 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.DBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.OLicensing Board 5.0 Selectmen's Office 6.[]Other Contact Person: Phone#: www.mass.gov/dia