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Home My WebLink AboutBLDG-22-003815 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' CITY YARMOUTH MA DATE January07,2022 PERMIT# BLDG-22-003815 1 �I JOBSITE ADDRESS 44 WINDING BROOK RD OWNER'S NAME HERRING CARTER D G OWNER ADDRESS HOLMES LISA M 44 WINDING BROOK RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES El 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 I 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 El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY El BOND El 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 Stale Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP El MGF El JP El JGF El LPGI 0 CORPORATION El# PARTNERSHIP El A LLC❑# COMPANY NAME ISTEPHEN A WINSLOW I ADDRESS. 8 REARDON CIR, CITY IS YARMOUTH I STATE MA ZIP 026641207 TEL FAX CELL EMAIL Iinspectionsldaefwinslow.com S310N M3IA3H NV1d #LI1Al2:13d $ :33d ❑ ❑ 11141233d 3H1 SV S3A13S NOLLVDIlddb SIHl oN saA S31ON NO1103dSNI 1VNId )C!NO3Sfl 101O3dSNI H0130Vd SIH1 S310N NO1103dSNI Sb0 HJl0H MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK vim ; 22- 3�5 ! _ ,_ CITY YARMOUTH (SOUTH) MA DATE 0110312022 PERMIT # �,s JOBSITE ADDRESS 44 WINDING BROOK RD, S YARMOUTH, MA OWNER'S NAME LISA HOLMES G OWNER ADDRESS SAME ...............j ___ TEL 508)394-7978 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL i RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: v ` PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS-. BSM 1 2 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 I UNIT HEATER UNVENTED ROOM HEATER MI _ WATER HEATER OTHER .. INSURANCE COVERAGE I have a current liability,insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY . 1 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 " AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted o- 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 1 a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (�� ` ? ....��i._p- PLUMBER-GASFITTER NAME ?STEPHEN WINSLOW LICENSE # 12298 SIGNATURE µ.me MP MGF , JP JGF LPG! CORPORATION # 3281C PARTNERSHIPS # LLC #. - -.„. '-' -- .. ....:LjJ COMPANY NAME:rE.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE �_ CITY I SOUTH YARMOUTH STATE LMA ZIP 02664 TEL 1508-394-7778 FAX 508-394-8256 CELL N/A EMAIL` INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts - Department of Industrial Accidents 9 .=,! Office of Investigations RI Lafayette City Center ^�� f/ 2 Avenue de Lafayette, Boston, MA 02111-1750 rt '�: S`f 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 99 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 10.0 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:01/01/2023 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 ins and penalties of perjury that the information provided above is true and correct. / 12/01/2021 Signature: â - A -_ Date: 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 30 City/Town Clerk 4.OLicensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia