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HomeMy WebLinkAboutBLDG-22-006379 ,— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK cn CITY YARMOUTH MA DATE May 04,2022 PERMIT# BLDG-22-006379 I-x JOBSITE ADDRESS 240 SOUTH SHORE DR OWNERS NAME PERLIN MARC G G OWNER ADDRESS PERLIN LINDA S P 0 BOX 310 SOUTH YARMOUTH MA 02664-0310 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL D PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 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 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. 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❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR • CITY S YARMOUTH STATE I-7 ZIP 02664 TEL 5083947778 FAX CELL EMAIL inspectionsnefwinslow.com S310N M3IA3H N`dld #11110: d $:33d 11141H3d 3H1 SY S3Aa3S NOIiV011ddd SIHI oN sai S3LON NOI103dSNI 1VNld /ONO 3Sf1 J0103dSNI 210d 3DVd SIH1 S31ON NOI103dSNI SVO HOfOd MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .%, CITY YARMOUTH I MA DATEL4/20/22 PERMIT # ZZ 3-7cf JOBSITE ADDRESS 240 SOUTH SHORE DR. SOUTH YARMOUTH OWNER'S NAME 1MARC PERLIN ___ __ GOWNER ADDRESS CPO BOX 310 S YAROUTH MA 02664 ______.1 TE 5083980496 _ j FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: j RENOVATION: 0 REPLACEMENT: E' PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ._ .. .:- BOOSTER .3L CONVERSION BURNER COOK STOVE DIRECT VENT HEATER .- ' DRYER FIREPLACE -;'. ---- _ i FRYOLATOR '�- FURNACE GENERATOR 1 I �, ,, , GRILLE i INFRARED HEATER _ _ I- _ aset- ;.......- LABORATORY COCKS MAKEUP AIR UNIT r"" — OVEN POOL HEATER ROOM / SPACE HEATER ' ROOF TOP UNIT I s+ 1 TEST 1 s UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER __ _ __ .. _ .. . Ai INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Li 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 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. O CHECK ONE ONLY: OWNER 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 accurate 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 I a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C-- --- ? ''''1/4 //4.4.4.10 ,^ ' - PLUMBER-GASFITTER NAME Fr-EPHEN WINSLOW LICENSE # 12298 SIGNATURE , MP ' MGF JP El3 JGF[ LPGI CORPORATION # 81 C PARTNERSHIP # ...] LC ❑# r \T-' COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING i ADDRESS 8 REARDON CIRCLE — L r, CITY SOUTH YARMOUTH STATE I MAA]ZIP 02664 TEL 508-394-7778 I FAX[508-394-8256 ] CELLI N/A EMAIL INSPECTIONS@EFWINSLOW,COM j r`. r-_ The Commonwealth of Massachusetts ' Department of Industrial Accidents 1� �� ,,�. Office of Investigations _- ' Lafayette City Center —74 - 2 Avenue de Lafayette, Boston,MA 02111-1750 ',,•,s 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-. ❑ RestaurantBar/Eating Establistunerit 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]** 11.0Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ 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. I do hereby cer ' the in a and penalties o_f perjur_h that the information provided above is true and correct. Signature: Y i // 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): 1.1=1Board of Health 2.1=1 Building Department 3.0 City/Town Clerk 4.0Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia