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Home My WebLink AboutBLDG-21-003927 MASSACHU-SET T T UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE January 15,2021 PERMIT# BLDG-21-003927 JOBSITE ADDRESS 183 SOUTH SHORE DR UNIT A2 OWNER'S NAME OCONNELL MARK A G OWNER ADDRESS 43 DEER RUN BELCHERTOWN MA 01007 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 PRINT CLEARLY NEW: El 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 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE 1 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 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 0 MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION El# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH S--ATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectio efwinslow.com • ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -.74s 4 6 0C% MA DATE wirovAngii PERMIT# 1-3-1-)6-Z i-00 Ic2 7 JOBSITE ADDRESS j . O 9 2— ',OWNER'S NAME I7, 72-k-__O_„4 L%, . -.....-_. G OWNER ADDRESS .. .ifl/IUc4-45n,.&� L I44 SW-- ' T EL...�3i53? iFAX L —----I _..� --I TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL Q RESIDENTIAL( PRINT CLEARLY NEW: . RENOVATION: Er REPLACEMENT: Li PLANS SUBMITTED: YES NOD APPLIANCES -. FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - - BOOSTER 111111111.111111111111111111111111111111111.11111111 CONVERSION BURNER i ! - ---- _ ---- COOK STOVE r i Mill Alm - DIRECT VENT HEATER ' DRYER __----- 11 -- -T- -----._ , FIREPLACE - FRYOLATOR l IIII FURNACE MA I, .___. _ _ OMNI ' GENERATOR GRILLE _ .. um ___11111111111a. mo r -_-_'�-=MI �� INFRARED immi HEATER ._.-._._ . ..-.___. LABORATORY COCKS _. - _1. _ __ __.___ 1111111110•1 111111110111111111311111111111 - ___ _ MAKEUP AIR UNIT � � --- '�I--- - _- i-. _ -_.. __ _ __. _ - _ !- - --- i _.. _ XII OVEN MMIIIIIIIII 1 I�MM POOL HEATER ROOM 1 SPACE HEATER _ _ ___ _-.___ 7111111 ROOF TOP UNIT _._.__. ; �I 111111111111111111111111111111111111111 TEST _.�.... U1IT HEATER ' UNVENTED ROOM HEATER __ __ _ IMIIIIIIMMIN111111111111111111111111011 MO iiii Inn ini WATER HEATER -. M1111.M.11111 111111111111111111111111 1 NM=hIN OTHER �--� r-- IIII — IMl_ . _ „ ___ ___ ----1111111IIM Mill11111111MEMMultirtiffiFMM. - - - - - - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch 14, YES a Is _7 i"" eN JAN I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW JAN 13 2021 { LIABILITY INSURANCE POLICY , ,.1 OTHER TYPE INDEMNITY L-.:: ON i l E DEPgkT OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required b • .. Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER El AGENT El Q 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 a P rtine provision of the PlumbingCode and Chapter 142 of the General Laws. , ' / Massachusetts State }� PLUMB ER-GASFITTER NAME STEPHEN WINSLOW LICENSE #) 12298 I SIGNATURE JGF LPGI CORPORATION # 13281 CIPARTNERSHIPD# . JLLC[ #Lr .- ,MP � MGF� JP � ® � � l - LOW PLUMBING & HEATING ADDRESS �, COMPANY NAME:) E.F. WINS I I I 8 REARDON CIRCLE ~'�' CITY I SOUTH YARMOUTH STATE I MA IZIPI 02664 1TEL1508-394-7778 ' ! FAX 508-394-8256 I CELLI N/A IEMAILI INSPECTIONS@EFWINSLOW.COM ' 'J l V r' ' ,. The Commonwealth of Massachusetts kDepartment of Industrial Accidents Office of Investigations Sr:g�=; ' Lafayette City Center j :ma 2Avenue 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.ID I am a employer with 90 employees(full and/ 5. ❑Retail or part-time).* - - Et 2.0 I am a sole proprietor or partnership and have no 6. Restaurant/Bar/Eating Establishment 7. 0 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 no employees. [No workers'comp.insurance required]** 10.0 Manufacturing 4.❑ We are a non-profit organization,staffed by volunteers, 11 ❑Health Care with no employees. [No workers' comp.insurance r[n 1 19 FiCithi *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 em_p_loyees_Belaw_is the policy information. Insurance Company Name:ARROWIVIUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.#1909A Expiration te: 21 1/2 Attach a copy of the workers'compensation policy declaration page(showing the policy number0and 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 :.4L_ Date: 01/02/2020 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): IsBoard of Health 2.1 Building Department 3.0 City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia