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HomeMy WebLinkAboutBLDG-21-006743 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1:-1-11411-2..)-S, CITY YARMOUTH F'y MA DATE May 20,2021 PERMIT# BLDG 21 006743 ' ADDRESS 56 MIRIAH DR OWNERS NAME BARSCH BETTY L JOBSITE G OWNER ADDRESS FISCINA ANTOINETTE R 56 MIRIAH DRIVE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 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 1 . GENERATOR . GRILLE 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❑ 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© MGF 0 JP 0 JGF❑ LPG' ❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(a)efwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El ❑ FEE:$ PERMIT# PLAN REVIEW NOTES . . ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -=--i.--- _ -.±aml_iM MA DATE ..54.N. /2.1...__ ____,' PERMIT # JOBSITE ADDRESS .,6._.Mki__brYlitirinedfinialt_ , 71 OWNER'S NAME GOVVNER ADDRESS .& int 1TE_Ve2q$ fb.if.tett__ „FAX . ; TYPE OR OCCUPANCY TYPE COMMERCIAL ri EDUC TIONAL U RESIDENTIAL E;1•-" PRINT CLEARLY NEW: rj RENOVATION: 0 REPLACEMENT: L... PLANS SUBMITTED: YES[1 NOD APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I-- ' - . --1 -----Am _tl___' BOOSTER L- ..' s , ti 1 11 . . .. 1 — . , 1 " 11 II CONVERSION BURNER _ ! ti. Li I i 1--I COOK STOVE -DIRECT VENT HEATER ' 0 1 . 0 , .. E. .7--! .... . . , _ .. . __.. .. DRYER 1 0 11111 _ __ ,I . : _- • IiiMIIIIIIIM FIREPLACE - - - -' - - -- . - - ---. ON 'I' _ 1------ :-. FRYOLATOR FURNACE ....___, n"--1- -- — . 111111111111101 BN B • 1 . GENERATOR _ E --I. . _ I 1 IIIII — rill' ---'-1 - -----=: ----71--:,----. —-----4---- GRILLE i 1 _ .1 _ . ._ .._ ____ INFRARED HEATER ' --"1 ---i r ; 111111iiii IIIIIIMNII— LABORATORY COCKS MAKEUP AIR UNIT OVEN i POOL HEATER ROOM / SPACE HEATER 1 „ _ . _ s. .L. _ „ „_, j..„,____ , 1.. __, ROOF TOP UNIT !i .11111 1 , _ . , IIMIUM UM: TEST 1.-1----,I I-- -. --- F---- 1111MWRIMMIMMIME _ 1--M • UNIT HEATER UNVENTED ROOM HEATER a .ETF-1 i _ iiiilit'F7 ,_-- :1.. ,,,L_,_ . ------ ' WATER HEATER .1 1 I- r 1 OTHER ---- 0 - 111111- 111111111.111_ :7------- 1 - -',L.,..L NW _ '1,---1 1 - - li _ Milt— tf.---- F- - 7J ._.17- i I MEIIIIII _ i ___ . LIT-----T—. . i _ _ fi ,__, , : ''ilaillig . ._ , _ _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES El NO 0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Fi OTHER TYPE INDEMNITY Cl BOND ri 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 0 AGENT Fi 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 complianc 1 a P rtine provision of the isi1 i Massachusetts State Plumbing Code and Chapter 142 of the General Laws. %. r- .."' ,APLa.01111%...S." t.. .1 (--- PLUMBER-GASFITTER NAME[STEPHEN WINSLOW LICENSE # 12298 1 SIGNATURE impl /:1 mGFF_ _ 1 JP 0 JGF D LPG! 1 CORPORATION ri# 3281C —I PARTNERSHIP EP LLC El# f COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING —I ADDRESS( 8 REARDON CIRCLE r.I CITY SOUTH YARMOUTH STATE[ kA---1 ZIP[92664 - —ITEL 508-394-7778 i FAX F508-394-8256 CELLb/A EMAILLINSPECTIONS@EFWINSLOW.COM i.... ...............__ ....__._. . ra. The Commonwealth of Massachusetts Department of Industrial Accidents _ , Office of Investigations _a Lafayette City Center r 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 employees working for me in any capacity. 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) [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]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health 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.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 r e the ins and penalties of perjury that the information provided above is true and correct. Signature: ,�' f,..,.��- 01/02/2021 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.OBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.ElLicensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia