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HomeMy WebLinkAboutBLDG-21-004993 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK iT-41, CITY YARMOUTH MA DATE March 04,2021 PERMIT# BLDG-21-004993 -77iJOBSITE ADDRESS *OAK GLEN VILLAGE OWNERS NAME daniel mcdonough G OWNER ADDRESS 120 BAYVIEW DR NOKOMIS FL 34275 TEL 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 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 ❑ 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❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ FEE:$ PERMIT# PLAN REVIEW NOTES { MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t.: CITY ---- Q1DG _2 ( - MA DATE r -�� 1 e ; PERMIT# CX1�-��i`13 JOBSITE ADDRESS y e. /. rI u U f ' o OWNER'S NAME 1_3A..oILLLI/Is.d,,,Qf.e.ag.,,A...1 GOWNER ADDRESS 125 /14V- ` b - wl�t 0004 104 TE4 11e FAX ...W. ^.gin.: r:_::.::..::..:...:_:_;._.=.:..r.a1=S s.._.� TYPE OR OCCUPANCY TYPE COMMERCIAL _ . PRINT EDUCATIONAL r_.,i, RESIDENTIAL�.�------- CLEARLY NEW:0 RENOVATION: 0 REPLACEMENT: Lc PLANS SUBMITTED: YES ID NO L APPLIANCES -1 FLOORS-) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER , 17 1 17.7 I .77 , 17 r1 ..._._._, _�.; ._,_.. �._ , � -.....- --- -.-.-. . - CONVERSION BURNER L._.1'L_ _ . ..._ 7 [-_.--_1: ._ i .... . _.' I. - 1_.-_ ._ _____._ .. I _�__ --._ 1____..-__I._ _ _ _1_ f_._-_-,.._ .. . . COOK STOVE � i 1 f•I � f ' __ ,__. . � __ i._ - DIRECT VENT HEATER _.___-...�..,: _ _.7: --- :_. ..� ___ - _ _ — u...w �Kv --ii- ---____-- DRYER [JI r— �1 _--__--_-i;L----�'[.----!`I.------J�.--,_-.,J 1.---__1 1._ I.__-_J 1._.—_;[ _.__.I 3 FIREPLACE - �- - .�:_.-...�__._._- .-.._. __ ....-_. 7. _. _..... _ � __. FRYOLATOR �_ -__. -I I-:...._-.._ - --I��L._- " t -_ if-7 r.r . 11-- -__.I.L_...__--_i- ___- ''�-.-_____ _-__ I _ ___11_.------)- '1_.__ - - FURNACE �7 17_ . . _. Cr. .-_ 1 - - - I. 1 ' --- 1.. -- --7-"-rr-__- 1. 7'[7- - - 1 i - ____-_I 17 GENERATOR 7: - _ :77)' 7-[ GRILLE L- --_- 1_- '-V L_ 7--_i l_- -T1--__I [__^ J 1__-- 1--_____Tr _1'1._.._-7t.-_--'.r--_- 7=-2 1 i, INFRARED HEATER _ _ T i i 1777.7.1 1 i 1 M _. - LABORATORY COCKS 1.- ,^'' 1 ____ .._,____ I--- - 1 - - I - 1 _ _ { ir L —`_ 1. __ __- _ .-__.-_� � _ MAKEUP AIR UNIT I . I _ - ' 1 --i-l.-�---i' _ 7 -7 _ . - I) -- _ . _-- _ __ OVEN 1T:--- , ___-- - `L--�~_' 1------' �,-..------'-1 --- 11 - I--..._.._I11.-.___-__ 1-1i-----__ 1----ir-1,1._.11_ ; POOL HEATER __-_.._..__r-__ 1.—__' ---- 1 I __ _ �_..__I �_^_Tf 11 ._.._...' . _-•'- --0,----- --- I f _____ 1-- --._ ROOM / SPACE HEATER - . a - ROOF TOP UNIT -Jr- _. _11_ )-i_ [1 _i'C^ !: 1._,_ 7L..___ ..►-. ^_i r ' L _._-I Lii TEST -.1 - 1 ii- ---i I: --( I - -` -__e_.1i 17..._.7 -- -- ._`1- -f`-__-_.11�7: 1,1---____1 i 1E7 UNIT HEATER .__ _ _ _.__._ _l:1_ --. l`I_ : _ .1 ►:1____.wJ I_-__... �'1..,_— _._r ff __ _ UNVENTED ROOM HEATER lr.:_-.,._i 1---�� - _____ir _ __i ----_I E ____).L _��_ JFL__-J 1.- --:'1- .`1 -- E---1 --3 1 WATER HEATER '° _ _ i �T _-_A.•..__._......_.__-._.___.___ ._....___------------_._,L_--�.� .__: .._ � 1___---.r.__- ._.' 1- �-------'L--- -- _ ----_ +-- -'4-- a-._--- ! -- - �1--r----~ ---- OTHER - - ' ._,_-7i L. _1 !; ------_I [--- -111 --' I. --. �-- 1----1- - --�:1--- -� --__� , . [--At. .. I. f rw6P"154wAlmw6'6.v414mv''461' xx� - -- -, 1 - ---- - --.._. _ ...--__- ------ i_.__.__-- _ ___ ------ �..__ �,,,A,r.,:r _ I .� ._..._..._.� { _ it ' - � �f � ._._ , INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Ed NO Lii I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ..! OTHER TYPE INDEMNITY1 BOND DI 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 LJ AGENT E_ 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 accurst 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 compliant a P nine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ISTEPHEN WINSLOW 1 LICENSE #[12298 1 SIGNATURE v\ MP [7.1] MGF El JP ri l JGF L LPG! L.I CORPORATION # [3281C i PARTNERSHIP # _ i LLC 0 COMPANY NAM WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE _w..x E E.F, cU CITY [SOUTH YARMOUTH LP- �� J STATE [hAl ZIPriiii6T---TELF5-6i2"3-9-41"7778-- - _ .�_ FAX 508-394-8256 ] CELL NIAJEMAILjJNSPECTIONS@EFNSLOWCoM �-' _.. �.�______. . ______ _ ._._.a...........______-._-_..__._..__- _.�. .___w_ ___,.., The Commonwealth of Massachusetts Department of Industrial Accidents l. -•.z 7 Office of Investigations MINIM 7 = Lafayette City Center t 2Avenue de Lafayette, Boston,MA 02111-1750 "e/ 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 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.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4.ElWe are a non-profit organization, staffed by volunteers, 11.0 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 Expiration Date:01/01/2022 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 ' le the ins�nd penalties of perjury that the information provided above is true and correct. Signature: 10 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): 1.0Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.El Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia The Commonwealth of Massachusetts Department of IndustrialAccidents Nat......._11) ! Office of Investigations pis Lafayette City Center ,c= � 2 Avenue de Lafayette, Boston,MA 02111-1750 awl `e a 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.El 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.❑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#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:01/01/2022 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 . c the i/ins and penalties of perjury that the information provided above is true and correct. Signature: r ' (t/^.... -- 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): 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 R- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a�lf_�t CITY / - ! MA DATE /'l j , PERMIT# QC DG_l(-001151 i 3 JOBSITE ADDRESS I1/6 Gi. - 7 ri corc i o1 i OWNER'S NAME Ouri. e i ii4CdOe6 iI G OWNER ADDRESS 12 5 Haiku` .W, .-� `E�-1 Ll - N �./�� � ! k/lGIA 0 i14f TE ��....... .. _.-�G r_.FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL I__ RESIDENTIAL[ - PRINT CLEARLY NEW:Li RENOVATION:Di REPLACEMENT: .-------- PLANS SUBMITTED: YES L I NOL APPLIANCES 7• FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 7- - .�.. -x _. I - E- E - F- 1.�_ I - - f _- BOOSTER L i -7t . !_ F i 1.71"_ _'I 1-71_ _'1 1 7 r77 i . I CONVERSION BURNER _...e,,,•,i j_, __ ;I yi.L-__ 1._. _`I----- I--_---_.I Ti _L. 1._ :, _ LT. 17 f_..--_-_ L._.___i.1_ 17. COOK STOVE 1-.--.�..L --'1--'1 ___:11. --- _---1- ._. i..---- I--_--1!---I-- i =1----LT DIRECT VENT HEATER r _ -_' - ' DRYER 1 [-r I 11 '1._-i.I___ 11 . 1 L I I I_ I_-_ I 11 L--- (I rf; FIREPLACE l...r.:.�1. -.- II 11L -�`I_-71I L._...(1-71. 1 - _,1 [--. 'I-_III` I FRYOLATOR 1r�I 1 r--1r r1- h 1 _ -I --:1- I,- ;1 1 '' 1 I FURNACE L1(._ _'[�;P-��:I-_ :1 IL- 71- ! `I. 'n !C (.1. . Jr7 _1 GENERATOR I-- I I 11_ (1- '`I 1I---- I '1_ _I I_ 'C i" ! _ _i - GRILLE 1____t 1_�__._1 —11711IE[�1:1131- 71___J[---- 1___:21-==f;[--7I_<��l -f: INFRARED HEATER 1 ._ 1. ._ _'1 r- i ISM I -_-_!1_._![1:7_7:1 '1_ (1____'1___ d -_1=7 E- i LABORATORY COCKS I -I I.. J 1 -,____I.____I _-__ 1___I L 1 l:� ____ �'L`I__._1 i_-__-'I.-__'1_-___I MAKEUP AIR UNIT 1- xi 1. E:77. -_..'I. -'1- ! _1 __1) __ ``I F III__:.-' IT_ _I ----'' 7: OVEN 1_ .�,w;I__...--! .�_- 1.-._ I-__-_fl---...__GI_.__.�! I i1-- I-----H-- '1T_tED_1T POOL HEATER 1 _: J1` 1--- 1---�'�-----_I"1 _ I ,�-----_i f-_+ __;1_ ;1_ _I1-�_LET__I ROOM!SPACE HEATER I......_.._1 --L_TiL... ._.__GI �`E___._.i :31-7E-,-�L_ _.II_--_ 1 �L---' ROOF TOP UNIT 1__ [_ 1____^,17.: .1 _j1 iT1 L=I �'1 __ [ TEST _ _ ___ UNIT HEATER 1._..._�FI _'I.--.-.-_ --11-----_I I _;:I 1l1------^1_T'1.-J`I---1____1 --1=-- UNVENTED ROOM HEATER 1:.._._I'I-___(1 [I _.i'_-__J.L---_71 ___-477____1_7_.E_J7E I- _ ___ r.:7 WATER HEATER L_ 1 1 1:1--_1!__._ I 'L_.__PI _.1_ -I it '1 11 __'1 Tr- I OTHER I i fT,11 i.1-l1__Ji_ 1�^P T1_I__I_.J[^iPT 1 r i�� -I 1 t I:I,_ 11.E Ti I _.%I _-- I I I__ �1. ; I _ i I___._-I`l.-. 1------I L L-- I_,-_-_Eli=_i 1.- 1 _i�1_ _, 1-_Ti ------11______ -I __._, . _ ti ____ „, 'L1 ;1.PT ►i _ 1°1-" 1;1 A _d_ __Ii=..�I i. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES E.I NO Li I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _; 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 L:-'I 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 compli`annc aajVPprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �� :/%1 • !J .r ----- PLUMBER-GASFITTER NAME!STEPHEN WINSLOW LICENSE# 12298 1 SIGNATURE v ., 1 MP � MGF I-1 JP LJI JGF LJ LPG'L�:�I CORPORATION U# 3281C PARTNERSHIP Lj#L LLC D#[ - COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS[8 REARDON CIRCLE N� CITY SOUTH YARMOUTH STATE MA ZIP[92664 TEL 508-394-7778 ,�- FAX 508-394-8256 CELLI NIA — EMAILI INSPECTIONS@EFWINSLOW.COM 1