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HomeMy WebLinkAboutBLDG-21-006638 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK SICITY YARMOUTH MA DATE IMay 17,2021 I PERMIT# BLDG-21-006638 JOBSITE ADDRESS 98 BRAY FARM RD SOUTH OWNER'S NAME BURNS CAROL H(LIFE EST) G OWNER ADDRESS C/0 GRAY DAVID 8 KATHERINE 98 BRAY FARM RD SOUTH YARMOUTH PORT MA TEL 02675 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0 FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 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 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❑JP❑ JGF❑ LPG! 0 CORPORATION❑#L PARTNERSHIP ❑# LLC❑it COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY IS YARMOUTH I STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections§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 ... — MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 71-4salg: CITY , __Y.SPvlibiftl.,_____,___ ____ __] MA DATE,SKI LZ, 1., ,,,,_,_:?, PERMIT # JOBSITE ADDRESS Miiktl._ !lien.4:1.. i iirriikli.Vid OWNER'S NAME . 6.41.1....___,., _.........._____ G OWNER ADDRESS .,. 4,M ., ,,.. ,,, ,, ________.: TEL 20.7,q.--7 5 3 ty:15 FAX t TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL Ej RESIDENTIAL it PRINT CLEARLY NEW: id, RENOVATION: ID REPLACEMENT: [11------------ PLANS SUBMITTED: YES Li NOD APPLIANCES -1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER • __ ._ ..' ' _____..._: ._ _ .._..... ...,_„,.., i BOOSTER 4 { . EN i - ' — - ma- i ail Ili CONVERSION BURNER COOK STOVE 1111111M ling MIIII NMI,IIIIIII WM IIIIII MI NE intimmotillilliniM DIRECT VENT HEATER 1111.11111111111111.111.11111.1111111111111111.111111111111111.111111111111•111 DRYER ' Mr _ FIREPLACE map! : - - ......, .._,..... ,,...,_., T..... n FRYOLATOR 'Ill ' iiiirW1111.li 1 =1111 ' 111 I 1 IIIIIIIIIIII.101111 FURNACE GENERATOR illiiiiii.M111111MINIMINAIMIIIMMUMMWEIIIIIII GRILLE WIWI ii. nit_ RIIIMMENINTM IIWM iiiiIMMEM INFRARED HEATER IIIIIIIIIIIIIIIIIIIIIIIIIWIIIIIIIIIIIIIIIIIIIIFIIIIIIIIIIIIIIIIIILIIIIIIIOIIIIIIIIIIIIIMIII LABORATORY COCKS MAKEUP AIR UNIT 1 nanan narnno-101-nr., OVEN IIIIIHIIIKIIIIIIIIIIIIIIIIIIIIM multionilluil ' , POOL HEATER , i----- - nninzo 55= a I . . ROOM / SPACE HEATER ROOF TOP UNIT 111111.1.1.11111111M11111111111111111.0.1MmilltiWONFORINI TEST MIN 111111Mr-rrinfiii 'n UNIT HEATER 11111M MIK MIK RIM IIIIII OM MIK MI MIII ,_,--.. ,--.---n UNVENTEDOMTEATR ilig ill.Mt 1111111,Ilii Willi_I IM 1 NM I mut fooma In tun lin WATER HEATER I ' OTHER ' — 1 1111 IT--- Lin 11111 ---.. „.,._ _ __ _ _ _ . . ._ , L__. - i - - -- lilt—, I _ MiiWM __ ----:_ _ WEW , 1 _ lint" - , C _ L _ . _ 1 , 1 WI il ___ :1 'W 1 __ 1___ .. ..,ET iimir--7 __ 77-7 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 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [71 OTHER TYPE INDEMNITY Li BOND Li 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 Li AGENT Li SIGNATURE OF OWNER OR AGENT <.... v. 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 i a rine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r ---- ....4.41..„ PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE #F12298 SIGNATURE '-- MP ['1 MGF .0 JP Li JGF 1 LPGI 0 CORPORATION Fl# 328161 PARTNERSHIP no „.....1- i Lc ric i Ai\ - -- V' COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE I --- Crl CITY SOUTH YARMOUTH STATE MA ZIP 02664 1TEL 508-394-7778 FAX 1508-394-8256 1 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents _p,_ '` Office of Investigations 'na r Lafayette City Center _d 2 Avenue de Lafayette,Boston,MA 02111-1750 -. 7",'', 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. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ID 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, 11.11 Health Care 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.#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 ins and penalties of perjury that the information provided above is true and correct. —Signature: Y -..-.I.--- 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 20 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia