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HomeMy WebLinkAboutBLDG-22-005632 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t,‘110Z1 CITY YARMOUTH MA DATE April 04,2022 PERMIT# BLDG-22-005632 Fi- JOBSITE ADDRESS 67 RUN POND RD OWNER'S NAME DAGLE KEVIN M G OWNER ADDRESS DAGLE SHIRLEY M 67 RUN POND RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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 I LICENSE# 112298 1 SIGNATURE MP© MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑#I I PARTNERSHIP ❑#I ILLC ❑#1 COMPANY NAME: ISTEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR, CITY IS YARMOUTH I STATE MA ZIP 1026641207 I TEL I FAX I CELL I I EMAIL Iinspectionsna,efwinslow.com S310N M31A2ZI NVld #IIWd3d $ :33d ❑ ❑ 11W2i3d 3141 SV S3A2i3S NOliV011ddd SIH] oN sa,& S310N NOI103dSNI 1VNLI NINO 3Sl ei0103dSNI NOJ 3OVd SIHl S310N N01103dSN1 SVO HOf10a _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .-�"1f CITY .YARMOUTH SOUTH) MA DATE103/29/2022 PERMIT# 2 Z� S��2 JOBSITE ADDRESS67 RUN POND RD,S YARMOUTH,MA 02664 1 OWNER'S NAME SHIRLEY DAGLE OWNER ADDRESS ;SAME J TEL(508)398-2131 JFAX TYPE PRINTR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL j RESIDENTIAL ."' CLEARLY NEW: v RENOVATION: REPLACEMENT: , PLANS SUBMITTED: YES ri N0P] APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _ if _ _, '. F� -f CONVERSION BURNER COOK STOVE DIRECT VENT HEATER �� DRYER _ �. _ �_ . FIREPLACE W. FRYOLATOR FURNACE ' " _ GENERATOR , GRILLE : INFRARED HEATER ..... �, :� LABORATORY COCKS l MAKEUP AIR UNIT 4-4 1 OVEN _..� - 4. - „ __ - _. .. _.. _. y. . _- � �.._�., _. . ,._. ._ __gym__ --- POOL HEATER 1 ROOM/SPACE HEATER r ROOF TOP UNIT "" _ `� � TEST ti e., e.� = � - _ U� w. _J--- �. , . r. UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 JNIIIIIIIIIIIAIMIIIMIIMIIIINIIIIIIIMIIMIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Mill i s r INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES F NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ; OTHER TYPE 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. 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 ii a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. p •nb. y -. ,.,.,. /�..�./ PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE#'12298 SIGNATURE MP MGF= JP JGF LPG' CORPORATION # 3281C ,PARTNERSHIP � # LLC # COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY -SOUTH YARMOUTH � CELL STATE MA ZIP;02664 �TEL l 508-394-7778 FAX 508-394 8256 N/A " �EMAIL>INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts 7 Department of Industrial Accidents 9 ` +'=' Office of Investigations 1. Lafayette City Center t 2Avenue de Lafayette, Boston, MA 02111-1750 M .1www.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 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.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4.ElWe are a non-profit organization, staffed by volunteers, 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#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$1,500.00 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 ' i the ins and penalties of perjury that the information provided above is true and correct. / 12/01/2021 Signature: Y --`°`'', 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 4.0 Licensing Board 5.0 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 ti=T 2 Avenue de Lafayette, Boston, MA 02I11-1750 �z �4 "`" „.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.❑■ I am a employer with 99 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.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0Health 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#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 $1,500.00 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 ' e the ins and penalties of perjury that the information provided above is true and correct. Signature: .........V.---- Date: 12/01/20 Y 21 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 3.0 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 ` ice 22� S��Z' f�f� CITY YARMOUTH(SOUTH) ! MA DATE 03/29/2022 ]PERMIT# JOBSITE ADDRESS 67 RUN POND RDLS YARMOUTH,MA 02664 I OWNER'S NAME SHIRLEY DAGLE , G _ a_ OWNER ADDRESS 'SAME TEL508398-2131 FAX .--. TYPE OR OCCUPANCY TYPE COMMERCIAL p EDUCATIONAL l�' RESIDENTIAL;: PRINT CLEARLY NEW:ID RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES Lrj NO APPLIANCES Z FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER NM MIMI BOOSTER ®---MI CONVERSION BURNER �a NNW 1 .11111111111.1111111111 COOK STOVE IIMIMMIII DIRECT VENT HEATER ® ®� DRYER WNW FIREPLACE FRYOLATOR FURNACE GENERATOR 1 1111=1111111 M. MI GRILLE ® ® ®®® INFRARED HEATER LABORATORY COCKS MI ® ®MI MIIIIIMIIM OVENUP AIR UNIT Willi Mill POOL HEATER 11.1111011111111111111.1111.11 ROOM l SPACE HEATER t ROOF TOP UNIT 2 'I TEST UNIT HEATER 11Ia: Ell ..,...._ --, UNVENTED ROOM HEATER 4- WATER HEATER ®������® pm OTHER _ ������� INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY �1 OTHER TYPE INDEMNITY BOND f, 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 Li 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 a Pprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Y/ ,".''�, PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE _ MP ° MGF JP JGF LPG' CORPORATION # 3281C ' PARTNERSHIP # LLC # COMPANY NAMEE.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH 1 STATE r MA I ZIP E 02664 TEL 508-394-7778 FAX 508-394-8256 CELLLNIA :EMAIL'INSPECTIONS@EFWINSLOW.COM _,_