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HomeMy WebLinkAboutBLDG-23-000181 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Z:1,11, CITY YARMOUTH MA DATE July 12,2022 PERMIT# BLDG-23-000181 JOBSITE ADDRESS 31 ANASTASIA RD OWNER'S NAME HOBBS VIRGINIA L(LIFE EST) G OWNER ADDRESS 12 VILLA DR FOXBORO MA 02035 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ 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 1 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 E 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 ❑ JP❑ JGF❑ LPGI ❑ CORPORATION E# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR 1 CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(a efwinslow.com S310N MIA NVId #11W213d $:33d ❑ ❑ IIINH3d 3H1 SV S3AUSS NOIlV0IlddV SIHI oN saA S310N N01103dSNI IVNId AINO 3Sfl N0103dSNI a0d 30Vd SIH1 S310N N01103dSNI SVO HJflOi! MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK q._ ;-‘,,,,. .„ CITY YARMOUTH MA DATE 6/27/22 _ PERMIT # 43 — 0/g j JOBSITE ADDRESS 31 ANASTASIA ROAD W-YARMOUTH 02673 I OWNER'S NAME CHRISTINE HOBBS ____ __ _ __ ______j G OWNER ADDRESS 12 VILLA DR FOXBORO MA 02035 j TEL 4016393322 JFAX IIIIIIIIIIIIIIII TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES NO"--" APPLIANCES Z FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER Li _ BOOSTER �-- .._ r - CONVERSION BURNER r �. .!--- 1---- E.. -MT COOK STOVE 1 J NNW DIRECT VENT HEATER i- 1... 1111111111 DRYER IT Milt FIREPLACE „r . a FRYOLATOR z.LF1_ �- � -� FURNACE __ ` GENERATOR [ - 11— —__ _- GRILLE i _ . PM INFRARED HEATER .L ,_ _ — -. LABORATORY COCKS 1 .. MAKEUP AIR UNIT L_ it ::�. _ ,,,� _.w _ L.__ ----1 OVENr. ___ I ! � POOL HEATER L. ' �._: . _. ROOM / SPACE HEATER ROOF TOP UNIT I _ TEST UNIT HEATER UNVENTED ROOM HEATER 1_______i=f 1I- _ _ WATER HEATER OTHER ----- . j_ 4,- INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES v NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v OTHER TYPE 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. CHECK ONE ONLY: OWNER AGENT Et 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 complianc I a P mine provision of the i Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C\--- r ' ' / r' r-r PLUMBER-GASFITTER NAME STEPHEN WINSLOW —I LICENSE #L1-?298 SIGNATURE MP 1❑ MGF [ JP ❑ JGF❑ LPGI❑ CORPORATION Q# [3281C PARTNERSHIP # j LLC ❑# COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS[8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE r MA 1ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL NIA EMAIL INSPECTIONS@EFWINSLOW.COM 4=7 s J The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Y= Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 wwx.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 7. El Office and/or Sa ;(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]** 11.0Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ 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#l. 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 ce 7 the ins and penalties of perjury that the information provided above is true and correct. ,,,,o4 01/02/2021 Signature: Y 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): I.❑Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia