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HomeMy WebLinkAboutBLDG-21-002658 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE November 10,202(PERMIT# BLDG-21-002658 JOBSITE ADDRESS 8 FOREST GATE VILLAGE OWNER'S NAME MCCUSKER JOHN W G OWNER ADDRESS CIO HENRY MCCUSKER 8 FOREST GATE VILLAGE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Ea 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/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 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 LICENSE# 12298 SIGNATURE MP©MGF 0 JP❑ JGF 0 LPG! ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsia)efwinslow.com �w 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 APPLICA TION ATION FOR A PERMIT TO PERFORM GAS FITTING WORK ��,,�1 IL.__�f----=-- CITY F1�?�. _�Jri NA W= MA DATEPERMIT mil . � i/.___�0 T # C.Lg,21-C ?! ' JOBSITE ADDRESSFF.7---071.0j4F__'r'v` �� i �4/Yj/I(J✓f !1✓� VC,( ti r - ..�~..�^,�. . . _.�_...__—_., _ ...__ _ OWNER'S NAME Isj-d�✓! /� v /,-r GR ADDRESS rYl� ..r:-.�. . . ..�.. _.- _.. OWNEp S 0 TYPE OR .._.. _. _� _Tn, ,�,,.�, E�� �-�- �� FAX ----� , OCCUPANCY TYPE COMMERCIAL ' � j PRINT , EDUCATIONAL 9�,., I RESIDENTIAL CLEARLY ��s NEW:I_.., I RENOVATION; -_1 REPLACEMENT; " PLANS SUBMITTED: YES r_,J NO APPLIANCES FLOORS-. BSM BOILER ! 1I.._ ti. _� "• y. -_ I _ - _a._ 9 - 5 6 . I t _ ,.is ii , I.__ BOOSTER -__n� �.. _ _� _.. � _ �� ..- '_-_�_ - _-. BURNER CONVERSION ----� Ji_ -.�__�_ 1 I G COOK STOVE - { I ��I I �` i i I^ _ ,_ I I E _,1: — L11:I_ am, - _ DIRECT _ _ _ _ _ ._- VENT HEATER DRYER 7 . _ . I 3 - ; FIREPLACE !.--- l-- - ` ' !._ I v i _ ' ,_ _-_ __ -- __ 1_ - ( I _ a FRYOLATOR --_..�'=--�-, _'�_ JI I - - - I_ GENERATOR I • I- GRILLE I-- ,fl ' ' ;,1.� j 14 I 1 - - - INFRARED HEATER .�� _-- r _� I ._j ��I._ 1 - I ... _ ..- I � i i i , I -- I �— --=--=. _ - J LABORATORY COCKS I - :�� __ _ - ---- z- - � ; _ '�- 1 I '�� I._ MAKEUP AIR UNIT ` I __- OVEN POOL H N _ _ _ - - - _, _�� EATER r ��_.l._-- -. �--. _,,. ��- - . . ::1 �� �� _ � a 1 � �I ,l i � �I a_ . i ROOM ISPACE HEATER -�_�. - �., . _ - _ _ _,1 . 11_ - I ...,. 'I -- I �2R 1 — . _.._ - 1 " fir € � ROOF TOP UNIT _; ----,,, _--- -, ---� _._- __ - . �i .;,"'_ �-��..�..._.� � .�..,,,' „ _ 1 TEST - �.-_ 1_.. � . i lI� �� � �- - I - _._- _ UNIT HEATER I �- ;q ( .. � it .-. _' -- it UNVENTED ROOM HEATER I _ z �;,4______r, :1IT I _ IR HEATER ___ _ r- -,.z— OTHER EI_ -LL- T„-. _.._ . _., .. I , I ,___ , 7_7 [- ----_—_-, 1---- -1;--- ---- #7— 'i-- --- 1 --------y= ---r- H -- - -- , i 1 , , . F j-- --j i -.- I.I --- a - I � .� — — ' ! - 1 it INSURANCE COVERAGE I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MG S - L. Ch. 142 YES ���-�; NO ?-_ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL OW LIABILITY INSURANCE POLICY .�: OTHER TYPE INDEMNITY `` - ` OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the r_:: ��rvu €.- Massachusetts General Laws, and that my signature on this permit application waives s coverage required by Chapter 142 of the pp t thihis requirement. SIGMA-SURE OF OWNER OR AGENT _ CHECK ONE ONLY: OWNER I T AGENT I� _. I hereby certify that all of the details and information I have submitted or enrered regarding this application are true an and that all plumbing wor< and installations performed under the permit issued for this application will be in com liancd accurat to the b st of my knowledge `� Massachusetts State Plumbing Code and Chapter 142 of the General Laws, p a P mine provision of the F� PLUMBER-GASFITTER NAME STEPHEN WINSLOW _.__._. __.__ 1 -- Y — .«.-•/^--- .� ______ LICENSE #L12298 SIGNATURE rs MP . MGF _�r JP l � JGF LPG! I CORPORATION ; # , _____.. _ f_ _ _ 3281C PARTNERSHIP _��#ILL_ LLC i i# COMPANY NAME; ELF. `WINSLOW PLUMBING_ `_ _ .__ �' r-�� ---J & HEATING �'ADDRESS CIRCLE ----�--���-----��--_ � REARDON CIRCLE � "-�`"`-M 8 �-�--.- �...,� �... ~ CITY SOU ___-._ ._. _____ _� ._SOUTH YARMCUTH STATE .__. _ ___ _._ _�� __ i_ _� _.._j MAZIP�02664 TEL508-394-77 FAX 508-394-8256 ('ELL N/A 78 EMAIL INSPECTIONS@EFWINSLOW,COM 1 3 The Commonwealth of Massachusetts w._ Department oflndustrialAccidents paw. Office of Investigations Lafayette City Center 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): 7.® am aemployer with-SO employces(full atdf - 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. ❑Nor-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#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' lei the ins and penalties of perjury that the information provided above is true and correct. Signature: 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): l f Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www man,vov/die