Loading...
HomeMy WebLinkAboutBLDG-22-005388 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ( 1 CITY YARMOUTH MA DATE March 25,2022 PERMIT# BLDG-22-005388 -`-s JOBSITE ADDRESS 224 KATES PATH VILLAGE OWNER'S NAME Joanne Peterson G OWNER ADDRESS MA 02537 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 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 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP 0# 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK —::As— c22 5 3 Sq suhis s CITY IYARMOUTH j MA DATE 3/15/22 I PERMIT # JOBSITE ADDRESS 224 KATES PATH YARMOUTHPORT 02675 OWNER'S NAME JOANNE PETERSON _Li GOWNER ADDRESS SAME TEL17743303147 JFAXL..... .. TYPE OR OCCUPANCY TYPE COMMERCIAL 7 EDUCATIONAL Ej RESIDENTIAL Li PRINT CLEARLY NEW: i i RENOVATION: Li REPLACEMENT: El PLANS SUBMITTED: YES 0 NO . APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER r_ , BOOSTER �. CONVERSION BURNER , COOK STOVE ._, . - . . is DIRECT VENT HEATER I_ .. ' _ _�__ — DRYER I� _ ___ , FIREPLACE � - FRYOLATOR FURNACE ,., ... ...LJ _ 4.3Sitra .. ... . . GENERATOR —, --_ _ 7.--;.--. -_-_.____- __ __Lczi _ GRILLE ( 7. L i _ Y '. `�' -_emu. INFRARED HEATER LABORATORY COCKS ... ... MAKEUP AIR UNIT �— i ;__r___ =--- = OVEN ._. f POOL HEATER ROOM 1 SPACE HEATER ,._� _,n._ : I, . ._ ROOF TOP UNIT _ r 3 TEST _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER i— ._ w- OTHER ^ ; r- - �. L _ 11 err e .,,. II MEM ✓ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES El NO El I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 1 BOND ,a. 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 ,4 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 L. and that all plumbing work and installations performed under the permit issued for this application will be in compliant i a P mine provision of the kiN Massachusetts State Plumbing Code and Chapter 142 of the General Laws. . / �y� r --- _a....A... -. PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12-298 i SIGNATURE NN MP RS MGF ® JP ® JGF ® LPG! [J CORPORATION [j# 3281C PARTNERSHIP®# 1 LLC LPL...1 Q-- N � COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE � rJ N CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 I N cra FAX[508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM zP The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center P Y t 2 Avenue de Lafayette, Boston,MA 02111-1750 �''y,� 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. 0 Retail or part-time).* _ 6. ❑Restaurant/Bar/Eating Establishment 2.0 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]** 11.0Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.1=1 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 e. 152 can lead to the imposition of-criminal--penalties-ofa 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 cerlif i/e the 1 ins and penalties of'perjuf�'that the information provided above is true and correct. Signature: 0� --k�.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.Board of Health 2.1=1 Building Department 30 City/Town Clerk 4.El Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia