The URL can be used to link to this page

Home My WebLink AboutBLDG-22-005199 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE March 17,2022 PERMIT# BLDG-22-005199 I'� JOBSITE ADDRESS 32 TABOR RD OWNERS NAME JOHNSON BRADFORD A G OWNER ADDRESS JOHNSON JUDY A 32 TABOR RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES El 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 GENERATOR 1 GRILLE INFRARED HEATER , LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER _ROOM I SPACE HEATER , ROOF TOP UNIT TEST 1 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 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY El 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 El MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: ISTEPHEN A WINSLOW I ADDRESS. 8 REARDON CIR, CITY IS YARMOUTH I STATE MA ZIP 026641207 TEL FAX CELL I EMAIL Iinspections0iefwinslow.com I S310N M3IA32J Ndld #iJIN213d $ :33d ❑ ❑ 111183d 3E41 SV S3A213S NOI1V3IlddV SIHl oN saA S310N NO1103dSNI 1VNId AINO 3Sfl 210103dSNI O 13OVd SIH1 S310N NOI103dSNI SYO HOf102J MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK T 6i mm.& a -_ .1?-:111681 CITY [YARMOUTH MA DATE 319/22 -1 PERMIT # S 115 JOBSITE ADDRESS 32 TABOR RD W YARMOUTH 02673 I OWNER'S NAME BRAD JOHNSON ____ _ ..i GOWNER ADDRESS SAME TE 5 )87754672 JFAXIIIIIIIIIIM TARP OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL El RESIDENTIAL El CLEARLY NEW:❑ RENOVATION: ID REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NOD APPLIANCES Z FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ii BOOSTER CONVERSION BURNER COOK STOVE IIIII IIMIIIIIEIIIIIIIIR _ DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR - - - - FURNACE ( III . - � GENERATOR OITI ..__--1. — 111111111111 GRILLE MI r INFRARED HEATER — . -- -- LABORATORY COCKS MI , . ____ MAKEUP AIR UNIT OVEN POOL HEATER , ROOM / SPACE HEATER ROOF TOP UNIT - _ i TEST --1--1 i ,.d.- ;. ,W,. ,aillIIIIMIMEMa.w .. UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1111'glint � _ _..: ; i OTHER �� 1 iiinsini INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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. CHECK ONE ONLY: OWNER [71 AGENT j p 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 i a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ? ,...,4.4r .J� PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE #I 12298 SIGNATURE v.orscMP Q MGF ❑ JP ❑ JGF El® LPGI ID CORPORATION U# 3281C PARTNERSHIP❑#�� LLC ❑#r ` J v" COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDON CIRCLE CITY 1 SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX L508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM j \ a • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _1.311_ Lafayette City Center 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.❑■ 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.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care 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#l. 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 ' e;the 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): 1 Board 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