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Home My WebLink AboutBLDG-21-005699 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE April 02,2021 PERMIT# BLDG-21-005699 JOBSITE ADDRESS 77 RAYMOND AVE OWNER'S NAME BOTTO CLAUDIA KOPF G OWNER ADDRESS BOTTO EDWARD L 51 MORAINE RD MORRIS PLAINS NJ 07950 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 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 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 0 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(a?efwinslow.com G 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 t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w, k. _APS __.._ . `' � _._.__ .'lit 1 CITY L.r�.,..• r?'10J 4r"� ( MA DATE I Z Z ] PERMIT# 'Y-D6-ti( " c 95. JOBSITE ADDRESS lkyadithv„e,..5„p.,,ia&/. i- 01 OWNER'S NAME Cctd• .,....®,: GOWNER ADDRESS 51 ill o(idt:L� ..w1Vw . t 5 •vi TE s 0 &1 4 - FAX ,. o « : r,e . j.nrvsnaw.wuN,.+nr. -.rt.--S,a.Zr�az x�mc.. S.tL TYPE OR OCCUPANCY TYPE COMMERCIAL[I EDUCATIONAL '1 RESIDENTIAL PRINT CLEARLY NEW:Li RENOVATION: 0 REPLACEMENT: (. PLANS SUBMITTED: YES L( NOD APPLIANCES -1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER �� G I i ..-�.1 -._-..,.a, ._..._, ._._.,� ..--..-_, .______._,,:_---._ , M _ _ .1717:7 BOOSTER - `i. . �- _. _ 'i... _ ..��I�:.--:uF��.:,1[:.�.._. !•,-____._;1. --:1 -�-,�-------- •I7T—_� ... _. is CONVERSION BURNER I i _.._ r____ i .._....__._E(.—_-_-_r{__ .__._ EL -.__-; --.- _- __, y_ • COOK STOVE L _ ' 1•------- -_—.''( ._`...i }-•-- .' ;..-- I--- -Tr.,_....' 1._.__ , i_ ) 1---_..1---- I----- _ - DIRECT ENT --- --- - - -� _. ..�:..., .....�..�. ..�,._, _..._ _ ._..,...._..._, ._._.._.�,VENT HEATER HEATER L ... is 1.------•-11:--- 1- -----' L---_i�L----._i 1. _. TT(---... 177. I�f-_ _1 I__-- --_-i: - - -'E.__..._.._'1_ _� L1..�..f DRYER L L 1 ^1�L___-- _�({- )°I-_-_---1 I,_._._,�1{�___ {I_-(:i_ J 1 f f'[.._..._� FIREPLACE 1, T�L r- .I{~ - _.('{. 7 _-�. !=-__._ ; E., - �_. - ..._.__ ,r-----� -7 FRYOLATOR 1[.,.. 1:1_ .. I-I_ 1` . _.. .-- _ , j _ __ (' �._. I _._ .__.._. ' FURNACE I� I ' [ !!� 1 __._-. I j 1"�_ _ --=1 i,1 T. 1•�._ �L, GENERATOR �_ .�,_ .,I I _ J --- 1_._.---''1._ - 1---' -______ 4.;,: { --. 1 , 1 __,[ J I _ ��- �-!� ---�•!._ ____ I__-- -IL_._I _ i GRILLE r. r.,1 I� __._..d--.•-I(. 11-31__-—_I__I �__.._____ [__ !_-___ 1-_-_7 L__._ 1- it ij L -�: INFRARED HEATER : 1- ----` -------.1'1T- i� -TT C---I ---- ii: _-_...':: .-_ .. --11- . I`1 1-- ----1 - ,1.1[7. 71.:! LABORATORY COCKS L I-L_____._I L,_ _._ I__ _I�1__.__ _i I__..__(1_.__.__I].._.____..'� _ ;1 - i ' I_-_.__11_ _-!I,__,_' _ _, MAKEUP AIR UNIT . ..<a r<�i.i..--. ' (V .7.-_(,_ -- ._' 1• l 1. _ I 1 --I1 - 177-.- :-.., (1{_ [.__ - [___---1 ___ . OVEN L- :I 1- _ I - - I`1 .. �'I--_!:L.___...__I.1_.-- _I .______l L .._._._I'1_____ �'1.1___f L. `-1.--. (E�, POOL HEATER L,-. __,�.____ ',1. -- -T-1' --- - 1 .�_' 1 _._.- ,:l.._.^ 11: __. 1...._ --;11- Y—- ,I ROOM / SPACE HEATER .w ...,. ..I .-----.-1 ----. is _.-- _ f 1_._._._. ' ;' "_�__~_' _ _.....___I: ._..__ ' .. ROOF TOP UNIT lz. I, _i L_r �(:L----�,1_- F11:11 i:1- ► __ -, 11 _- i' I, I. -j. ,: TEST • �_ . _ .��_-____. L...�.,...._..;�_ _+__ �.._..:.:��•-_ __ -- --- - .. . . - y ' - - 4 --,► _ - _ i I �._. 1 I .� 1. _r,i -J 1_--_J E -(1-. =► [ i UNIT HEATER. 1 I 1,I_,r-. _i�l W 1 fl ,I ?I-.- UNVENTED ROOM HEATER[. TG - _ .i17.:73 -. __11 -----i•L____J _ L-_ ! I--- .- ''L . ' '` . 1� -.L. , T WATER HEATER ,1a:__L)1._ .-- --.-i= - .--11 -- -_ I_ -1.I______(L-- -- -1,----I (11 ___ i IT __' _- I OTHER _ I --,.I r _I L-____J -1 i_____ I I l 1...-- - i�L �:i.-_-�'(- I- .-_ : w__. .l._�iISBKP,}Hlf.'l�ii'-.1i'ci:.?biS�vir;._:1_#i_Si.�_ _7�_ S'wkS. Y id38�iiG•+Fx"3:uiiS�. cSY£:. __ _-_- I__ __A_...__ ---- __ ,_ _ ' ^,J 1 -_ __. __ .3 _I 1 -- T ED= . 1—__ ___ ., [......___1_._r_I�._. � 1..- - -_ -. [_ -•--___.. _ _ 1: .1 1_ .�! _ .7 _ _ , '' _ -! . I,f - i :• 7 - . � II_ �i1------' — : ,,..rwx:ala cgxrmar . ..1rmucawl+anue•xa�--aL--M, r,-,,.-,,.—,tuusC,_ INSURANCE COVERAGE _ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES II• NO 0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ '{ OTHER TYPE INDEMNITY [ 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 171 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 best of my knowledge liant and that all plumbing work and installations performed under the permit issued for this application will be in comp a P rtine provision of the :--- Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 10 AL. ......../---- '* PLUMBER-GASFITTER NAME [ STEPHEN WINSLOW - �J LICENSE #1:12298i SIGNATURE MP [ ] MGF 7 JP ___,__! JGF E ; LPGI L ii CORPORATION , # [3281C 1 PARTNERSHIP #L ,_; LLC D#�__ ^ l M COMPANY NAME:[E.F. WINSLOW PLUMBING & HEATING ` JADDRESS 8 REARDON CIRCLE s CITY Jsoum YARMOUTH STATEMA ZIPff0264 1TELfro8394-7778jj -- __ �__ I__ FAX[508-394-8256�- CELLLN/A ^�� ,_jEMAIL1NSPEc1oNs@EFvNsLow,COM ^- +___ TM The Commonwealth of Massachusetts Department of Industrial Accidents ' j Office of Investigations Lafayette City Center { �e 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.El I am a employer with 90 employees (full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.El I am a sole proprietor or partnership-and have no 7. U 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.] 12.0 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:01/01/2022 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. ido hereby cer ' ief thegh�ins and penalties of perjury that the information provided above is true and correct. Signature: Y 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): 1111Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.0 Other Contact Person: Phone#: www.mass.gov/dia The Commonwealth of Massachusetts Department of IndustrialAccidents Ft Office of Investigations Lafayette City Center 2Avenue 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. I am a employer with 90 employees (full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.El I am a sole proprietor or partnership and have no — — 7. Li Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8 El 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]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' of the ins and penalties of perjury that the information provided above is true and correct. ,fJ �j/% 01/02/2021 Signature: 7' "` �^- Date: Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): lUBoard of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -c� Tig ® CITY .YA r✓101J_I/t- MA DATE,3/Z -/z a� PERMIT# Z.L D6-fit" c • JOBSITE ADDRESS L1216/ 5cjailidsWAo OWNER'S NAME C,J ap r4t2u _j__..,.._.___ ,.. GOWNER ADDRESS [S I Motajrie &V iVlo/i(5_94inS NT 0 7150 I TELt50$,91 •1 f FAX(_, _ TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL Li RESIDENTIAL[L— PRINT CLEARLY NEW:® RENOVATION:ID REPLACEMENT:C.. PLANS SUBMITTED: YES 0 NO[„ , APPLIANCES Z FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ _ — BOOSTER i _ r rI ,4 _.x.. 1- .. f , rL.,_.._.�'I '1 1 1-= I ,-=� — -- is CONVERSION BURNER -I_..__. -_ii._._..__I(__._.Fr _I J I !I- -7- r -71 tI�-I COOK STOVE . T'L----_;L__'I_ ..a l.._._. - !_. - I_-.._.... 1,_ _ 1- ---.1 .__ 11 -- I --.1 I_---'I•---._ DIRECT VENT HEATER L.__._...I ._._._ii1___.___:'I. __.._�I_-J,_--- L___-�I--__-_1r-_-_�•l-- ir ._w1-__._- L_.Ti _ 'L..,..,_.r DRYER _.,''�-I1- _I;I_____EL_-!�1__._ 11..7I-,_31- _-.-fI.�-II- 1_--1:L_.__([ 1rTD FIREPLACE I....p.,..._..II rr Il 1L. . _1L _--1 (._.. .'I 1I k I 1._ 1177E7 FRYOLATOR 1.____ L_E A___,_ r___.__y1__-11=I T___J ____J(._.-.. _ :r_-_: _._.J 1il__._.J: FURNACE r ._.J ._ri .._ : Fr.7. 'I -71- 1r - 1-7FT_._-�_-�(.._ _.. ((.:.._-f _ E-� GENERATOR II,._.. -JI•__JI-- _III._... II-- f__ 1I -I'. ''h._-�,1.---_!r 11 -II_._._ I D GRILLE I za_w__._ 1 -1 _i= i i__1 r=_- _____ .____ I. _-1�.--f[77 L I_T INFRARED HEATER _,-._...a L..__! _.____1E-77 -' - _L-.._,I• ._-..11.____-kl__.___.J!iI h-`L_--I1= 1 E;_-__! LABORATORY COCKS 1.m_--__)1.--._I _,___II_____r1_.____i I _IL_.__[I______L__ MAKEUP AIR UNIT 1y-c,.aai 1 ....!1. _.._I: __ _.!'L .-`'I .. ...I_�_.-_f l.__77I ,I.- -_111 L--- I - _1 11 . I, OVEN 1 -11 _ I s1____J l..__._1. _ __------_-1____l _ _i-___1I- ?1 L_ _ .. _ POOL HEATER L-�1' 1- I _I I I f(.. - __ l �r _I_ i I. i ROOM/SPACE HEATER L__,...! J.I^__.! mo- 'E _ !i _ J-- 1'�- L--_ .7_1 E _.7.—_�L--I! ROOF TOP UNIT 1 L_ L�J1 1_-_ ,1--111JJ1__ L 'I._ _ 1 ILj _ -7 TEST _:..i1. . __,II-._.__�I-.--11_ 1..._ IL- I ` _ ra-,-_1L__- Ir7EI ___ 11----I UNIT HEATER I _J __I`: _,_.,,j�I �._P I 17- I•:I___.__(I__ 1:I_____..II-?I_-__._11 [ UNVENTED ROOM HEATER L,,.,�.,_ _J1 i1=,. _I'_.._._J __ I.___J, ___J(___I L_ G1,-=1LD_ L..-..J r I'1---_.__ WATER NEATER IEI. __ J __I__ '!_-_ .I`L. 1l_�_I `I 1 I:L_.r_i ____i%____i ![__I OTHER !� -7-7I I;Etil- I II .I Ett7 ':I fir- `17 �- 'I - ��.,� , ,.-_. 'L___I L_,-__ -'I._____ __it_ F_731.-_._t1._ I I_--- L__ I 1-- 1-71 '1__ ..�.t - .(�_.t . ..J`_____1� 1___--1 �f 1- f - I\ f i 1 1 MI1__....r 1. -.1- -!'>---- -_. -I'I.. 4...7. r—_.k'I_ Jl fL..!. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES +I NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY l OTHER TYPE INDEMNITY Ej 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 ® AGENT El 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 compliant a Pprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. %1 ' !� cD ? -,. ,,,,,..._ — PLUMBER-GASFITTER NAME I STEPHEN WINSLOW I LICENSE# 12298 SIGNATURE MP Pi MGF® JP[111 JGF 0 LPG'[-I CORPORATION U# 3281C PARTNERSHIP 0#_ I LLC , i#L- 1 , COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE _ -J CITY SOUTH YARMOUTH STATE MA ZIP L02664 . T FAX 508-394-8256 CELLI NIA 'EMAIL INSPECTIONS@EFWINSLOW.COM __ ---