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Home My WebLink AboutBLDG-22-002678 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kg- CITY YARMOUTH MA DATE November 09,202'PERMIT# BLDG-22-002678 f,>=� JOBSITE ADDRESS 104 NORTH MAIN ST OWNERS NAME BLAIR CHRISTIAN G OWNER ADDRESS CADWELL ANNA 6 SPRINGTIDE LN HARWICH MA 02645-2436 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL PRINT CLEARLY NEW: ❑ 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 ❑ 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 he 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 1 SIGNATURE MP El MGF El JP❑ JGF El LPGI ❑ CORPORATION❑# PARTNERSHIP El#I ILLC 0# COMPANY NAME STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(a.efwinslow.com wsw- S31ON M31A321 NVld #11Wb3d $ :333 El 11W2i3d 3FI1 SV S3A 13S NOI1d3llddV SIH1 oN sad S310N NO1103dSNI 1VNId A1NO 3sn ,10103dSNI 803 39Vd SIH1 SlION NO1103dSNI SYJ HJf1OH MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - —s r—. ftwi� , CITY YARMOUTH MA DATE 11/01/2021 ' PERMIT # 2 6 JOBSITE ADDRESS?104 NORTH MAIN ST, S. YARMOUTH, 02664 IOWNER'S NAME CHRIS BLAIR ---r GOWNER ADDRESS '6 SPRING TIDE LANE, HARWICH, MA 02645 ( TEL IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL c EDUCATIONAL = RESIDENTIAL PRINT CLEARLY NEW1 RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES NO i APPLIANCES Z FLOORS-0 BSM 1 2 3 4 5 6 7 8 T 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR II FURNACE 1 .__ GENERATOR .,,, .�..n1 GRILLE r INFRARED HEATER LABORATORY COOKS MAKEUP AIR UNIT _ OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER. OTHER µ,, .,....n x. .*.... .-, :_,,..**. ;, INSURANCE COVERAGE V3 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES v NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 'w'::1 OTHER TYPE INDEMNITY BOND Ci 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 , - 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 O and that all plumbing work and installations performed under the permit issued for this application will be in cornplianc i a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ` 11/4/) 0 ? ' /„.".....4,1_,-. cS-7.. PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE '69 MP n° MGF JP r JGF LPGI CORPORATION *mv # 3281C PARTNERSHIP # LLC # COMPANY NAME. E.F. WINSLOW PLUMBING & HEATING ADDRESS l 8 REARDON CIRCLE CITY SOUTH YARMOUTH 11 STATE MA ZIP 102664 TEL 508-394-7778 FAX 508-394-8256 CELLI NIA EMAIL INSPECTIONS@EFWINSLOW,COM The Commonwealth of Massachusetts Department of Industrial Accidents 9 =49 Office of Investigations lrt it Lafayette City Center `—'1'") 2 Avenue de Lafayette, Boston, MA 02111-1750 .-fir-. 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.❑■ 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. ❑ 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, 11.0 Health 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)// ' the �in�s��nd-penalties of perjury that the information provided above is true and correct. Signature. 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): 1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.DLicensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia