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HomeMy WebLinkAboutBLDG-22-000019 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE July 01,2021 PERMIT# BLDG 22-000019 JOBSITE ADDRESS 91 QUARTERMASTER ROW OWNER'S NAME CUMMINGS JOHN A JR TR G OWNER ADDRESS THE 91 QUARTERMASTER ROW RLTY TR 700 FRANKLIN ST GREENEVILLE TN TEL 37745 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 1 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 0 JP❑ JGF 0 LPG! 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(u)efwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El FEE:$ PERMIT# PLAN REVIEW NOTES . , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK p.C..1i= CITY � _�c,[N!.d�J Gl___ _. __ -_.__..-____.. MA DATE r6721-1/.___...,, PERMIT# l�LDG-2Z oubdl9 JOBSITE ADDRESS 11 Ctvath[dflu5i-e1 Low , . .. ;, , 1 OWNER'S NAME j,1 i C jyl,z,,,v OWNER ADDRESS 5CnMI? _... TEL�SLZSS 5..�7_ 7. FAX..- , PPENOR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL D RESIDENTIAL CLEARLY NEW:Q RENOVATION:0 REPLACEMENT:�� ---- PLANS SUBMITTED: YESD NOD 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 FIREPLACE I_ 1 i ( , FRYOLATOR FURNACE I I GENERATOR i GRILLE NM NMI Mell M LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER , 1 ROOF TOP UNIT 11111 n TEST 1 UNIT HEATER OTHER l j I I Y I r- I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO C I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE INDEMNITY Li 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. CHECK ONE ONLY: OWNER El AGENT LI 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 st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc a Firtine provision of the c Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,fJ >�3a 'LICENSE#'12298 , SIGNATURREE PLUMBER-GASFITTER NAME'STEPHEN WINSLOW l - MP El MGF® JP LJ JGF fl LPGI 0 CORPORATION J#13281C I PARTNERSHIP 0#I __ _I LLC D#' _ _ _ __1 COMPANY NAME:'E.F.WINSLOW PLUMBING&HEATING 'ADDRESSI 8 REARDON CIRCLE t-jz, v 0 , , CITY 'SOUTH YARMOUTH ' STATE I MA 'ZIP'02664 ITEL I508-394-7778 FAX'508-394-8256 1 CELLI N/A 'EMAIL'INSPECTIONS@EFWINSLOW.COM __ The Commonwealth of Massachusetts Department of Industrial Accidents ,x_' s l Office of Investigations =2`= ' Lafayette City Center ow 2Avenue de Lafayette,Boston,MA 02111-1750 "5,„' 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. ❑Retail or part-time).* 6. ❑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. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 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.] 6 12.0 Other ��� �_ _ _w.._.__ *Any 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: --'olicy-#-or Self--ins.Lic. 64A Expiration Date:01/0_/20 2 --- - ----- 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 cer' e the ins and penalties of perjury that the information provided above is true and correct. ' / Signature:�w11 1' ,."+'-"- Date:01/02/2021 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): 10Board of Health 2.0 Building Department 30 City/Town Clerk 4.0 Licensing Board 5F1 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ ; Lafayette City Center lam' 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. ❑Retail or part-time).* 6. ❑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. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.11 Health Care with no employees. [No workers' comp.insurance req.] 12.0 Other *Any 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 4-or-cif-in_s:Lic. #4964A• 01I01I2022 — 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 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 cer ' e the ins and penalties of perjury that the information provided above is true and correct. Signature: �* f....l.�- 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): 1.jBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.[]Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 _Err ms i7 Y _ __ 'z OU6bJ _ MA DATE,61 6"IV.� r PERMIT# I1t_DG-2 9 .� CITY c�l�`'�;Psl �__�,__ _...._ _.._ JOBSITEADDRESSI11_20LIKC®1?a51-1_1a.51.41 . OWNER'S NAME La ki, 60jv;•v,,AA S..____.._...._...._..__. G 01. �664 OWNER ADDRESS ,_... N'e _,...n.,_. _.._. I TEL,50$3.C_.7.5 6 .._7..___,;FAX ....._..._.._._...._......_. TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL jJ RESIDENTIAL PRINT CLEARLY NEW:I:j RENOVATION:L. REPLACEMENT:L--- PLANS SUBMITTED: YES[ NOE] APPLIANCES 7. FLOORS--4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 4 BOILER BOOSTER � . . CONVERSION BURNER ! I ! COOK STOVE ( ! I DIRECT VENT HEATER I .. _ 1. DRYER FIREPLACE FRYOLATOR FURNACE I GENERATOR INIMI [ GRILLE INFRARED HEATER LABORATORY COCKS I ! MAKEUP AIR UNIT OVEN ; _._... POOL HEATER 1... l ROOM I SPACE HEATER I :!�a _ ! s ,. !_. I .�_ _ . I ROOF TOP UNIT _ ,. ! TEST I = I ( I UNIT HEATER .._.w _ _.._ !,_ -- 17NVI=VIED ROOM HEAT(=t _af I /h I WATER HEATER OTHER . I__. = _.- I 9- 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [NO I. 1 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE INDEMNITY Li BOND [TI 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 0 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 accurate to the st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compiianc, a P rtine provision of the c_, Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , ,,,., ittiz PLUMBER-GASFITTER NAME(STEPHEN WINSLOW I LICENSE# 12298 SIGNATURE MP EI MGF® JP 0 JGF[i LPG([I CORPORATION 0#13281C I PARTNERSHIP®#l. . _,___,_,,I LLC al, _ _ 1 ` COMPANY NAME:I E.F.WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE � A CITY I SOUTH YARMOUTH I STATE' MA I ZIP 02664 TEL 508-394-7778 M V FAX 508-394-8256 I CELLI N/A (EMAIL INSPECTIONS@EFWINSLOW.COM 4-N