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HomeMy WebLinkAboutBLDG-22-005164 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK it CITY YARMOUTH MA DATE March 16,2022 PERMIT# BLDG-22-005164 JOBSITE ADDRESS 123 STANDISH WAY OWNERS NAME Chris Douglass G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q 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 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 ❑ 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 I LICENSE# 12298 SIGNATURE MP©MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑it PARTNERSHIP ❑# LLC❑# COMPANY NAME: ISTEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR, I CITY IS YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL 1 EMAIL 'inspections(thefwinslaw.com 1 S31ON MJIA321 NVld #JIW2i3d $:33d ❑ ❑ II11b3d 3Hl Ste S3AN3S NOIlv3llddv SIHl oN s8A S310N NO1103dSNI 1VNId AlNO 3Sfl b0103dSNI JOd 3OVd SIHI S3lON NOI103dSNI SVD HOfIOZI T MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 7615 CITY YARMOUTH J MA DATE 317/22 J PERMIT # •-c2.-- S I (.. 5 _ JOBSITE ADDRESS 123 STANDISH WAY WEST YARMOUTH I OWNER'S NAME LRIS DOUGLASS .,..,ave,••••,,—*A GOWNER ADDRESS SAME I TEL 6177996358 I FAX L. .H .,,...._1 TYPE OR OCCUPANCY TYPE COMMERCIAL 7 EDUCATIONAL 0 RESIDENTIAL EI PRINT CLEARLY �_ NEW:D RENOVATION: ¶ _. REPLACEMENT: El PLANS SUBMITTED: YES El NOEI APPLIANCES 1. FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER .� BOOSTER CONVERSION BURNER I- _ . COOK STOVE T DIRECT VENT HEATER I _ DRYER .. _............_ }. ._.._.. ' FIREPLACE FRYOLATOR --'..1r i� FURNACE _ _r-- _ It; ----_:_:-....:_ GENERATOR I ___-_ GRILLE -__-&a..a.____=,� INFRARED HEATERS LABORATORY COCKS MAKEUP AIR UNIT OVEN ... POOL HEATER . _ 1� ROOM / SPACE HEATER ROOF TOP UNIT I l I _____ TEST 1 I m . .m.m. UNIT HEATER . UNVENTED ROOM HEATER .._._. _ .,,, - . WATER HEATER �. . ----- --_OTHER ___-___ . .,�,,, ,,,�. _ .��. . I ., - -- ......_._.......t... , . — v.....L.- --- INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES El NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY j 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 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 complianc a P rtine provision of the NN Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (..3 -D--- ? ..."‘ 04.44.41L PLUMBER-GASFITTER NAME i STEPHEN WINSLOW LICENSE # 12298 SIGNATURE r' - MPH MGF El JP ED JGF El LPGI D CORPORATION E# 3281C PARTNERSHIP 0# LLC ®# w , Ln COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING 1 ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 I FAX 1082 CELL NIA EMAIL INSPECTIONS@EFWINSLOW.COM cD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 11 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. 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]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0Health Care 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. Lie. #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 ce ' e the ins and penalties of perjury that the information provided above is true and correct. � _, ,,,,�� 01/02/2021 Signature: — 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): 1.0Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5O Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia