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Home My WebLink AboutBLDG-19-004898 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r�6 BLDG-19-004898 �� CITY YARMOUTH MA DATE February 27,2019 PERMIT# JOBSITE ADDRESS 19 CUTTER LN OWNER'S NAME HENSINGER BRUCE A G OWNER ADDRESS HENSINGER YVONNE M 8299 WINCHESTER LN ALBURTIS PA 18011 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES D 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 ❑ 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 Q MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL accountspayableta7efwinslow.com S310N M31A3H NVld #lIINa3d $ 33d ❑ ❑ 111%13d 3H1 SV S3Ai13S NOILV3IlddV SIHI oN saA S310N N01133dSNI IVNId WINO 3Sfl 210133dSNI 80d 39Vd SIH1 S310N N01133dSNI SVO HOl0H MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Iii = CITY V4YrYi (71 MA DATE Z i s iC/ PERMIT# i 1 /t W917 JOBSITE ADDRESS jq a�.4-1/ Li (,J• `IGc v 140,01 OWNER'S NAME ,e h 4 e / -4- tor 70 . I--c (1 GOWNER ADDRESS IG55 f yi L sit-. I'h h, ku.rn 41 '')c4' TEL.(e175o1/!3 vv co FAX TYPE OR I 7 1-77 PRINT OCCUPANCY TYPE COMMERCIALS EDUCATIONAL 0 RESIDENTIAL 1 CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: E PLANS SUBMITTED: YES❑ NOC] APPLIANCES 7. FLOORS--► BSM 1 2 3 4 5 6 7 8 9 10 ER 12 13 14 BOILER ��I� �� BOOSTER 1111111111111151111111111111111111111111 ; .I CONVERSION BURNER 'v COOK STOVE w 11111111111111111$ ir3 DIRECT VENT HEATER - DRYER FIREPLACE 'FRYOLATOR rFURNACE M1 ,,1111111111=ww _,._ i GENERATOR �'® �!�:�I�i�,l is! �I®,ME 3 _ GRILLE = = l INFRARED HEATER ® �li l® ® ' .� ....___1 LABORATORY COCKS �I� � � � �1� �� li �=-_-_ MAKEUP AIR UNIT t� OVEN — .� _ --- - POOL HEATER .„ -- ROOF TOP UNIT i 'i UNIT HEATER 1 , ( WATER HEATER � � �;� � � �L� � ��l J , OTHER ;®I� ® '_1 i pit- JK 1 1111111•1111111111111111.11111111111.111111111WIIIMIIIIIM INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO E. I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY n OTHER TYPE INDEMNITY ❑ BOND ❑ - ' _r, 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 L .] 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 know,?ige and that all plumbing work and installations performed under the permit issued for this application will be in compli " e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE # 12298 SIGNA RE MP [] MGF❑ JP ❑ JGF❑ LPG' ❑ CORPORATION E]# . 3281C PARTNERSHIP❑# LLC ❑#{--� COMPANY NAME: EF WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE , ____] CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com I A lii. liV/IWIILV/W IYi.Ii LWIb VJ 111t .3 LLl.IL 64J 8.LLJ Department of Industrial Accidents _;411"1 Office of Investigations I= _ 600 Washington Street VI • Boston,MA 02111 ligwww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ii (� ( Please Print Legibly Name(Business/Organization/Individual): E.C*•��i r S I ow Q 1khe,00 ki.,cv Q� t 4,,n c fir . Address: �e �, C _ City/State/Zip: Sou.c tcro-x.),,(-n A- Phone#: 503- 3c 9-112C3 Nre you an employer?Check the appropriate box: Type of project(required): I am a employer with 70 4. [ I am a general contractor and I " ! (fa and/or art-time have hired the sub-contractors 6. ❑New construction l I I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions ] I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13.0 Other applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. iec.'rrw s who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. actors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site .mation. •ance Company Name: AfirOW c-1..1 kJ'cA (�j' t,.l(.12.. :y#or Self-ins.Lic.#: I '3 al Expiration Date: (—( - ao9 Site Address: !wv\cyr) J CVNe3,64. IA•111 City/State/Zip: OD Li io mach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 1u,1 to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Tie up to 1,5UU.UU and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine Fup to S250.00 a day aainst the violator. Be advised t,at a copy of this statement maybe forwarded to the Office of tvestigations the DIA for insura overage veril on. do hereby certify un e e ains an penalties o p'jury that the information provided above is true and correct. ignats�es A Date: (a 3 i 1 am'? hone#: 431)7,:35'1 7 77g Official use only. Do not write in this area,to be completed by city or town official. • City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: