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HomeMy WebLinkAboutBLDG-21-004865 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK "T v _I/ CITY YARMOUTH MA DATE February 26,2021 PERMIT# BLDG-21-004865 - JOBSITE ADDRESS 1108 BAKER RD I OWNERS NAME (WINCHESTER RICHARD P G OWNER ADDRESS (WINCHESTER NANCY R 29 RANGER RD NATICK MA 01760-3231 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 ❑ OWNERS 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 IStephen Winslow I LICENSE# 112298 I SIGNATURE MP©MGF❑JP 0 JGF 0 LPG(❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ISTEPHEN A WINSLOW ADDRESS. 18 REARDON CIR, CITY IS YARMOUTH I STATE MA ZIP 026641207 TEL I FAX I I CELL I I EMAIL IinspecNons@efwinslow.com 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 APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i if= $ CITY JAL' MA DATE -1 1,Z Jl ,j PERMIT # VA-DC, Z l -06 1960 JOBSITE ADDRESS haiksiL • /rn ijj OWNER'S NAME aTuri C iit1,`H c 1e5 4-cr.., . .. ,, . GOWNER ADDRESS 2. 3, a " .r 1>A A G 11 G b. i TE ?--? 6Yi.JFAx . . __ ._..__ ._.. [ TYPE PR NT OR ._.OCCUPANCY TYPE COMMERCIAL ] EDUCATIONAL I RESIDENTIAL , - CLEARLY NEW: n RENOVATION: Li REPLACEMENT: I PLANS SUBMITTED: YES 11 NO[ '1 APPLIANCES 1. FLOORS—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 . BOILERA 1 I J BOOSTER .71. CONVERSION BURNER �..,..;`1_ , ._.- ; [.=...T_ i.E . 1 _.. I. - i I [..__... 1 _. ' I - 1.-_-_..- -~1._-_-__-� L- C. 1 -.-... COOK STOVE ' i i l DIRECT VENT HEATER _. -� v_m.- .1 ` _ . ._ ' _ ET._-;,_ T. __. A .�y_._: -�-n._ _ �,I _ ' :' DRYER ,_ _ -- i• _ -_--I�F----- 1-- - h------_I L_ - I--- 1_ -_i�i,1_ l_---11 ��._: [. —__, 11__ _J FRYOLATOR I _____ [-,-- --'�[- 1T .-- I - _.. . I-- --;:1 !.I . _.._''�_ 1 ''1- I FURNACE .�-.�"7 ..._ _". . ! ["—.77 _i f- _ ,, _u,_,__.i ! ��._...'1-_ _ ,,�.:e�....__ 1 . --__.' 1 , . ._ I El� ' i . - I - - ---�I.----- �� GENERATOR II 1 _ I • - - __._. .�._._..._,L.�.. - ,_ GRILLE Ir-----. 1-, ^._.__I^__`7_'_,11 - _---_I 1�_—�� _— i_- i_—_7'- L_ INFRARED HEATER [.- -,:[_. ._ -- C- ---' I' �.�.__ : i--- ---' 177. :____ _ - __1:1 . 11_-____--11-�----171 ______F I � LABORATORY COCKS 1,. ___�I,"___._ .` _ --V_i`L__,__I .._-__7 -__I _.__.___I I.u. 11 - ? - --_' __.- ______17_ _-_- I,____._` [_�__I MAKEUP AIR UNIT r- . .. :1 r ._1 I - _ _._ . ._! 1. '.i _. . I __._.__,1 '•1 - .. r - Ali.--- - 1.. _. _ I:r__ --- -- __'' _. OVEN L. ---- ---- 3 -- -- ; __ --i 7-7 _.__.._1 -.._I _____- --• ---_--__I4 —1 _' POOL HEATER :-.._.._.....^! -----'1----_'.1-_._--1'1---_. ..._':1-. L_..__t1.. .__... ' � ---__[ .__...CL—_— _- _--I L__---11-- I ROOM / SPACE HEATER [�..:....._...11 _f 7_.. ..----- -':1...- I ______i----- .- -1j-- --- -� E7 i --!:fl-__I' __-_: .. -1.L-----' I_ - - ;: ROOF TOP UNIT 1^— -1 C_ -- ' ._. ' [_..�._��[-__ �__. _I_C— I I - - 1.— I7LI---� --' 1. -- TEST • :- „I - --Jr.-__.7 f - _ . - 1_ r .[.� ______ ----__ ' 1----- UNIT HEATER .�r „,� � ,s �--� — _--� �---� --� 7� ._�1 t r __ - I2 --- -�.�_-r,__ 1_ '-i :I— :1_---_- I___... �,1 _ __ fi_____r�l- -I C _1' UNVENTED ROOM HEATER I. .... [- --_ ITTT ' ..___ T11------'-E-� I �-'L----`�_I-- . ' —'' _ _ _.._I. _-___.- I i7 WATERWATER HEATER [ ;° -` 1 F:1. � '—_ 1,________! __-----}I__ -- ----, I i.1�- ''----' — ~1-- .__..._.._ _.._._._._._.._.______._.____._._____ __ - .-- ._-.- _-- . _-._- "----- �I � _ fir_--- _--.- 71 OTHER' . _._.--..�. . i 1. -T 1__ -' L L----il!-----I i_ i----- .[--�: [-- 1_— _---- 1---- --I E-77 7._ .I i-- - .--- - -1- ' EL .. . iGt6L."23� � '' �k- 'fir:.xraFG:"'..,si3' —� ----�.._..------t----- 'e ._ _ -.._..-�. _ .____�q __.�.._ __.__.___. __..._— ---- i—�-- .,.,,,r-r- --_._ i I -i.i 1. �. �� :1 I 1� 1„. .. .. . .:. � .� . : ... ._._ ____if-_____i �...__._., I-..".�.--_� I_--.-___.1_..__.._� ,.., _.. 1..-- 1:-----.. i._---..--_._ _11.___ -...__ I----,____ 1•--__- I. - - . 1 [. _ .._ [ -_( . _ .__If _--_- i;1 ►sr--: -.I.. .1 . 111�r . -- ----. :I-__._.__11_ _��`I_ . _ I. �.....4411 4.6Wat..'ltil t1Y'��.tiL Y =Sit"FMWp�Y6CV. .Gf it44.. -- INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1 NO La:. I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ri.'I OTHER TYPE INDEMNITY ar 1 BOND D 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 0 AGENT Ell k.. "R 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 compliant a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r.. PLUMBER-GASFITTER NAME DTEPHEN WINSLOW LICENSE # 12298 SIGNATURE O '� MP I � MGF _ JP r_.._' JGF T LPG! .._,I CORPORATION 71# 3281C _.. 1 PARTNERSHIP ._ __ � '' _ - ��v� LEI :. # .: .,.n ., LLC�i#�t.r-:_-. .., ; -j--- COMPANY NAME F. WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDON CIRCLE z CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 1508-394-7778 1508-394-8256 CELL NIA __.._._.___._..._.........--_.._.....__.....__,.._...... FAX �_�� JEMAILNSPECTIONS@EFWSLOWCOM _ The Commonwealth of Massachusetts - Department of IndustrialAccidents —Mr.. Office of Investigations Cu'�= ' Lafayette City Center in' 2 Avenue de Lafayette, Boston,MA 02111-1750 `Ay 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): 1.0 I am a employer with 90 employees (full and/ 5. ❑Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0Office and/or Sales(incl. real estate,auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.Li 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]** 4.0 We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *My 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 ' e the and penalties of perjury that the information provided above is true and correct. Signature: Date: 01/02/2021 ?' '` - I -'- 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.OBoard of Health 2.❑Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia