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Home My WebLink AboutBLDG-21-002553 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 9 CITY YARMOUTH _J MA DATE November 05,202( PERMIT# BLDG-21-002553 .-17 tiff JOBSITE ADDRESS 63 SOUTH ST OWNER'S NAME CASSIDY JOANNE G OWNER ADDRESS 63 SOUTH ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 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 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/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❑ 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 0 MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(c,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 •1--- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r=c . s. 1 CITY Yc{r`"c;,/1.1n MA DATE 10 I D--1 ' PERMIT # /3L/De i CZ JOBSITE ADDRESS 7 Sc J 4-1-1 S -e r OWNER'S NAME Jc inn Cc)3( - ` Ct i GOWNER ADDRESS Co3 5C-J W S\ -k TEL S O• 3`i Y-?3 'I ) FAX N IA TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL Nt: -- PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: [Sr PLANS SUBMITTED: YES ❑ NO Et- APPLIANCES Z FLOORS-I 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 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 r g 1 INSURANCE COVERAGE i i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES N NO ❑ ...,— rn I IF YOU CHECKED YES. PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW _ _..__ ., LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ [ :B9P1____^1r '`' L�Er�ART�y" %ijJ S---) OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 14) Massachusetts General Laws, and that my signature on this permit application waives this requirement. 0 CHECK ONE ONLY: OWNER El AGE-NY El SIGNATURE OF OWNER OR AGENT 3 I hereby certify that all of the details and information I have submitted cr entered regarding this application are.true and agcurate t the best o m nowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliau e w h all P rtinent prov s n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. LA.N.---- PLUMBER-GASFITTER NAME LICENSE # NATURE ---_- J MP' MGF El JP El JGF El LPGI El CORPORATION El # PARTNERSHIP ❑ # LLC El # et COMPANY NAME1-flAAtAAIv‘) eltivv-V;bed A?,�_il�k ADDRESS (t�C\rt..� .r L-k CITYSCok/t^ /bfVC,Jt' STATE M ZIP O 6! TEL FAX q.Y3- 3YI4,). CELL ('J IN EMAIL t enpQC k1LS et, .„1," I ceivx The Commonwealth of Massachusetts Department oflndustrialAccidents ' — Office of Investigations L is r .71 1tr�= Lafayette City Center 2 Avenue de Lafayette,,Boston,MA 02111-1750 44- 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.❑l 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]** 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 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. Lic. #1909A Expiration Date: 01/01/2021 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: 7'A("` 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): 1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.['Licensing Board 54=1 Selectmen's Office 6.❑Other Contact Person: Phone#: •