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HomeMy WebLinkAboutBLDG-21-001141 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • k" CITY YARMOUTH MA DATE `September 03,202 PERMIT# BLDG-21-001141 JOBSITE ADDRESS 73 INDIAN MEMORIAL DR OWNERS NAME WHIPPLE JOHN M G OWNER ADDRESS WHIPPLE JOANNE D 12 VENTURE TER GLENMONT NY 12077-3512 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El 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 GENERATOR 1 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 ❑ 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©MGF 0 JP 0 JGF❑ LPG! 0 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(adlefwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION hik. 6:a, / Yes No O k 0 0�4L Jy u 2 o C f5 THIS APPLICATION SERVES AS THE PERMIT El 1=1 r FEE: $ PERMIT# PLAN REVIEW NOTES r r . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r 1, ,f,--kf '-• tJ CITY ....Y MA DATE �S/2 1 PERMIT# 13 <<� %- � �r /' fr1 ,4ofIJ1 / l OBSITE ADDRESSu� 5.��M t 1 OWNER'S NAME ISohr�:F' . , _ ,:� G .,,,,fir, OWNER ADDRESS v, pj _Lai_ 1 TEISOg61GS °I :FAX1 TPR E R OCCUPANCY TYPE COMMERCIAL 7 EDUCATIONAL L' RESIDENTIALI: �INT CLEARLY '—' PLANS SUBMITTED: YES n NO D NEW:1_,r_ RENOVATION: I i REPLACEMENT: 4. ; APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER -- ----- .. . . _ .-. -- ;----- ----- -----• ---- BOOSTER i ! CONVERSION BURNER !_ - - • C00 K STOVE 1 DIRECT VENT HEATER i '_ I --- ; �. I I i _ DRYER ! I I - ) - ) ! I j FIREPLACE I I . . . . - - --- FRYOLATOR . ! I ' `. �F 1. FURNACE I I t• 1 it- ,-, 4.- . ,.. , ( . 1 1 a ( UL GENERATOR _. 1 ' 1 GRILLE i_---- : I _____ - --- --- _. . - - ,- _- . _ __... --- -- i _. - • INFRARED , 0 1 - . '_ . . f i _._ ' { �'� ! LABORAT•-,o ;- - IZ ' __ !� _• ! .. i 1 ! - I I ._1 - - �- ... . . 1 ._ MAKEUP Al' Q ' - - 1 I I ' C _ I l 1 i I 1 I • :. I OVEN . -- i_ • __ • . . ._ . I. . _ .. I_. _ . . " I . - : I __ - I ) i POOL HEA a* a 1 . - ---- --- - -- )- - - — --- --- - ROOM 1 SPA AT in ROOM i ; - _ i ,- 1 _ -- - - - a • , . i ROOF TOP I .0 ' ' • TEST ;z UNIT HEAT- - _ . - •- -_ ! _ ; _. UNVENTED '�J , - m •m ! ! WATER HE' ! IR I _. . OTHER i - ! i i ! 1 • I 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES { NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY,CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY I f' 1 OTHER TYPE INDEMNITY , BOND L,-_ 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 .F�' AGENT I. .: 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 b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc it a P rtine provision of the - Massachusetts State Plumbing Code and Chapter 142 of the General Laws. S PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP _�.. MGF JP r_ JGF Li LPG' CORPORATION ,#13281C 1 PARTNERSHIP I.',#D ____ LLC 7 #==',..3 rv--, COMPANY NAME:t E.F. WINSLOW PLUMBING & HEATING -�� ADDRESS 18 REARDON CIRCLE _ . .�� __ CITY r SOUTH YARMOUTH 1 STATE ! MA I ZIP E 02664 TEL [508-.398-7778 1 __ --------FAX 508-394-8256 CELLI NIA EMAIL INSPECTIONS@EFWINSLOW.COM _ _._ .. The Commonwealth of Massachusetts Department of Industrial Accidents _' Office_pal- '; ff of Investigations Lafayette City Center .��— �`J 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.El I am a employer with 90 employees (full and/ 5. ❑Retail • or part-time).* 2.[1] I am a sole proprietor or partnership and have no 6. ❑RestaurantlBar/Eating Establishment 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.Cl 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 ❑Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *My applicant that checks bqx#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#I. 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 hi 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(t 1 o .the ins and penalties of perjury that the information provided above is true and correct. i Signature: CM) p ,...‘,/ 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): LOBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia