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HomeMy WebLinkAboutBLDG-22-004305 q� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE [February 03,2022]PERMIT# BLDG-22-004305 JOBSITE ADDRESS 25 JACQUELINE CIR OWNERS NAME TEATOM ROBERT J G OWNER ADDRESS TEATOM ELIZABETH STONE 25 JACQUELINE CIR WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL D PRINT CLEARLY NEW: ❑ RENOVATION:❑ 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 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 1 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 0 NO 0 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 at 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❑ LPG! 0 CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL insDectionsnaefwinslow.com S310N M3IA321 Ndld #iIW2f3d $ :33d ❑ ❑ 1I0183d 3H1 SV S3A213S NOLLY3Ildd`d SIHl oN seA S310N NOI103dSNI lYNld AINO 3Sfl 210103dSNI 2JOd 30dd SIH1 S31ON NO1103dSNI SVJ HJl0m . , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k�" .lL , _;4�, CITY YARMOUTH MA DATE11/26/22 I PERMIT # JOBSITE ADDRESS i25 JAQUELINE CIRCLE 02673 I OWNER'S NAME LROBERTTEATOM G r_ OWNER ADDRESS ;SAME 11EL5087719307 FAX a TYPE OR OCCUPANCY TYPE COMMERCIAL i EDUCATIONAL El RESIDENTIAL _ PRINT CLEARLY NEW: El RENOVATION: ' REPLACEMENT: 0 PLANS SUBMITTED: YES El NOD APPLIANCES -1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER �. : . _ �. BOOSTER . ii— CONVERSION BURNER M COOK STOVE — r , - ----- DIRECT VENT HEATER I------ DRYER _,,,,..„1-7 4E-7 _ —11 _..ir _ _ FIREPLACE FRYOLATOR _ FURNACE —` — GENERATOR Pri GRILLE , ._. . — . _. . INFRARED HEATER ' LABORATORY COCKS MAKEUP AIR UNIT _ OVEN _ , .� - ,., .. POOL HEATER 1 '' _ s ROOM / SPACE HEATER 4 ROOF TOP UNIT 1 ,,, it TEST __: i- -,.. UNIT HEATER _ _ UNVENTED ROOM HEATER . WATER HEATER 1 I _,, �F__,... _ OTHER I _ _ ;._ F _ - ice.:_ .- _... .. -. � i --aiiiilaiallii.L -.Ea, INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES El NO Li I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 I AGENT ED 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 rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r ---4 ..044.4.4"- PLUMBER-GASFITTER NAME STEPHEN WINSLOW i LICENSE #112298 SIGNATURE MP v MGF ' JP ® JGF® LPG!® CORPORATION E# 13281 C PARTNERSHIP TI# ILLCLI#I.-...._ _:.._. .n.J N "7- COMPANY NAME:° E F. WINSLOW PLUMBING & HEATING ! ADDRESS! 8 REARDON CIRCLE 0 n CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 1508-394-8256 I CELL1 NIA !EMAIL' INSPECTIONS@EFWINSLOW.COM :—\-j-' The Commonwealth of Massachusetts ,� Department of Industrial Accidents — ► Office of Investigations 'r ' �l� ' Lafayette City Center t 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: Business Type(required): 1.El I am a employer with 90 employees (full and/ 5. 0 Retail or part-time).* 6. ❑Restaurant/Rar/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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.ElWe are a non-profit organization, staffed by volunteers, 11.0Health 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 cer�t the ins and penalties of perjury that the information provided above is true and correct. Signature: 0) Y ~ 4 Date: 01/02/2021 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): 1fBoard of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia