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HomeMy WebLinkAboutBLDG-21-005947 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK tic7:43;. CITY YARMOUTH MA DATE April 14,2021 PERMIT# BLDG-21-005947 JOBSITE ADDRESS 6 HIGH GROVE RD OWNERS NAME TIGGES JOHN L G OWNER ADDRESS TIGGES ANTOINETTE M 122 WEBSTER ST NEEDHAM MA 02494 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 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 El 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❑ LPG! ❑ CORPORATION❑# PARTNERSHIP El# Lc ❑# 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 El ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK TV-,, CITY ,t� MA DATE a; - �� ...- lt �.a�a..<.'J PERMIT# JOBSITE ADDRESS l i_g_> (D 6))5i-Xv OWNERS NAME / viva ' l ee i GOWNER ADDRESS 1.1.1.,1.!12 `V•er i•-< <, Ply 0'1 qg'I I TEL15083i1/0 “6 _IFAXl....__...,....._ ,..,.1 TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL t RESIDENTIAL[ PRINT L�J CLEARLY NEW:J RENOVATION:L_ I REPLACEMENT:(_ PLANS SUBMITTED: YES® NOD APPLIANCES 1 FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I LJ 11 J[ _.._,_n..,..... sE 1.1- I _.i is_i( i i_ `i -- i BOOSTER 1,-_-_,:i... i -' -•-..IiL F[. . L,7. _,.I . . 'I l.1-77,1. I.7.-r r.. _ .I: CONVERSION BURNER . u..._�..„'I .. 1 __' ... 1.- -Ir- �- __J -- ....I L _.!1. -' _ ,.1T >. I )�..._. COOK STOVE 'I�-- i---1 .____--i 1- __-I.__.._��h..^...;i,_.-- 1.-----.I 1 _-=i_ - I I_-__1 Im___. DIRECT VENT HEATER E. .11._.__._..I 1 'L _--31_--i L.71. 11 !1 _-___L__-__�T_ __-_ L I_.._.._ _ 11 _.1 DRYER L... r�r-it _L._—J i___f I_7 L-.-.-�-_-_1 _ .f:L__._J( T r r FIREPLACE I. '1 �.. .1 i'I.- .1'L..-W..1I_ _....it ,. .!`1. .1�1., 4... `1<-----' -- i 1.7- ET FRYOLATOR 1 1__T_I 1 ,.-_i:L__,_.-.'l___�11_.. f L�_iI T.-_J:—:(__�__1 L_�1:_._.__�'_._.J'(, l I_ .._...1 FURNACE -11 . '( 1f 1__ . i lr ,.1I. _ i� el i.L. .._1 .__ ,1ffiL....-- .7.-7. GENERATOR 1--.M,.,...I i i ---I'I--11l---3 1--=1------1------I . __ 1------'i.--_11 f 1 'L.... i L------I GRILLE 1 JI (1 1 I71 --`1--i —F1- 1 r-�I-- (��- II---JI 2 INFRARED HEATER t..J L-77 ---. E--J.L--T' -_ I 1----,11 ..k1.-----I 1 ,--_._I'�,'I-__L _11—_JE.:,---- LABORATORY COCKS 1,.._.....A__.-I1__.__121_ _Il_.. _i1 �1_ J1--_-__--iL '1_--�`1,.rl_.__ {--_-- 1__ _I;I__ MAKEUP AIR UNIT _'I ._1:r i._ . ``1. .-.II_-_I1.�_,.�1 7..i:I- 111.,..I�L.-.___I:_�-1r -1�1� OVEN 1T_a,.._11__.--_-__i -1i1 .'`I--f l___._.__J 1 Ti l.____l1_.___O___J 1�T_1�..J1E J 1 TI LJJ POOL HEATER ( _.. _ 1 _ 1_ -.�'1 JJf--JLui r- 1 I _I. -_ ROOM/SPACE HEATER .-.'1.__.__I.1-___-!` -"l..-- _o_____I'1__-._..J L-----J 1T-'ia 2I _ [77. rTT 1 i` ROOF TOP UNIT .,11t—_i ({=1 I 11-_-,J I I L— I 1_---I c.I i.�V L1-_ ,1----__i ----7: TEST • 1�„__-.i1 ., __,11-- rr_ _ II(_._. -.II_. ' .T r.__ .I `[ i, tl J1�--TA._----11_.-_� r_ 1 UNIT HEATER 1:::-.1 _I:.-.-_`f . 11._._J It 1 t _-I. ;L._J` Ef_-_f 1v I[-1 UNVENTED ROOM HEATER ;1-__((,�__i� , r.11._ _,I'l___-_J.�J:1 J;I____ � ?1 1r _ WATER HEATER L _I1.,..__._'l___TJ1-_..-1I___._.;L__.L__1 J'1_ i�ILr '1 -'i - -'�- L ___I OTHER 1 L ;1 i, i -7I- r f ,........-,v.[Mu r-«3.,,,u,Su,... 6 r, .nkovn• INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES j 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 0 BOND EJ 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 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 a1YPrtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298_1 SIGNATURE - , MP �J �MGF I JP 1TJ1 JGF 0 LPGI L(1 CORPORATION 0#13281C 1 PARTNERSHIP # i LLC D#L _l COMPANY NAME:1 E.F.WINSLOW PLUMBING&HEATING ADDRESS r 8 REARDON CIRCLE - __ i CITY l SOUTH YARMOUTH � _ _ I STATE(� MA�ZIP102664 _1TEL 508 394 7778 y --- _,., ,.,,, 1 FAX 508 394 8256 CELLCN/A IEMAIL1 INSPECTIONS@EFWINSLOW.COM �„ 1 The Commonwealth of Massachusetts "- ' - Department of IndustrialAccidents l ii�lUV . Office of Investigations • _ Lafayette City Center lill : 2 Avenue de Lafayette,Boston,MA 02111-1750 '41-11- 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.❑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 $250.40 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 "l' �ef the/�wins��nd-penalties of perjury that the information provided above is true and correct. Signature: `J> I. lr 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.[]Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia