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HomeMy WebLinkAboutBLDG-21-000744 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE August 16,2020 PERMIT# BLDG-21-000744 JOBSITE ADDRESS 310 GREAT ISLAND RD OWNER'S NAME SERGENTANIS GEORGE A G OWNER ADDRESS SERGENTANIS IRENE P 120 TENNYSON DR LONGMEADOW MA 01106-2141 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:0 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 2 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 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY 0 BOND 0 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 j LICENSE# 12298 SIGNATURE MP 0 MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. Ie REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX I I CELL I I 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 ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES `` •s MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK m W-j CITY I__ �� :- - : MA DATE[1L U JiLl PERMIT # LD& -�/'000i JOBSITE ADDRESS W G/ '0"__ _�_ 11 cLW J.A'M!V OWNER'S NAME ,Trf/1O SG �11 i . ----- _ --- - ' GOWNER ADDRESS 1 Q `1( 1 San Q y� I E 5O$Z !FAX TYPE OR O M& ;- PRINT OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL RESIDENTIAL E — CLEARLY —' NEW:I RENOVATION: �.�_ REPLACEMENT: =, --r PLANS SUBMITTED: YES I-___ NO _ 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 I____—_ DIRECT VENT HEATER E_ _ DRYER ! FIREPLACE FRYOLATOR FURNACE a i ,_ GENERATOR - GRILLE _ INFRARED HEATER - LABORATORY COCKS MAKEUP AIR UNIT = ; OVEN POOL HEATER ROOM / SPACE HEATER I- ROOF TOP UNIT I _ TEST ' i UNIT HEATER UNVENTED ROOM HEATER WATER HEATER _---___ OTHER INSURANCE COVERAGE INSURANCE\ll1YV COVERAGE - I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. C "" THETYPEOF COVERAGEAPPROPRIATE BOX BELOW _ _ -�CEIV - I IF YOU CHECKED YES, PLEASE INDICATE BY THE AP R 1 LIABILITY INSURANCE POLICY 1. OTHER TYPE INDEMNITY isJ 30 D . �µ I I ,tiq p 2020 eg qOWNER`S INSURANCE WAIVER: I am aware that the licensee does not have the insurance covera re uired b.' C Pter 142 oth�e Massachusetts General Laws, and that my signature on this permit application waives this requirement. BUILDING D PA TIVIK UT CHECK ONE ONLY: BY GENT 7- 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 -.O Massachusetts State Plumbing Code and Chapter 142 of the General Laws. egze 0_) 1" --... ,.....Q‘ 4.- PLUMBER-GASFITTER NAME STEPHEN WINSLOW I LICENSE #f 122. 98 I SIGNATURE _ O --, MP I '__ MGF I JP JGF LPG! = CORPORATION # 3281 C ' PARTNERSHIP _ '# LLC #I LF t ry COMPANY NAME.i E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE Ju_ �_______I CITY SOUTH YARMOUTH - ' i STATE ! MA ZIP 02664 TEL 508-398 7778 FAX; 508-394-8256 j CELLI N/A EMAIL INSPECTIONS@EFWINSLOW.COM liz- i Z0 Z0 - G ,y Q 2 s o� v � yob 7m 2 sG 3 /2 ►vl[ i 1 S -*- t,JiG. 9)Y /37cr The Commonwealth of Massachusetts Department of Industrial Accidents Office of Inves?igritions '. '' , =a lg , �. Lafayette City.Canter * ]'�— 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: I Business Type(required): 1.11 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]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0Health Care with no employees. [No workers' comp. insurance req.] 12.❑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#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 ' •the 1 ins and penalties of perjury that the information provided above is true and correct. Signature: � �/? ^` ......"....— Date: 01/02/2020 g 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 5.0 Selectmen's Office 6.DOther , Contact Person: Phone#: www.mass.gov/dia