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Home My WebLink AboutBLDG-22-003360 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY IYARMOUTH I MA DATE 'December 13,2021 PERMIT# BLDG-22-003360 f JOBSITE ADDRESS 48 WILDFLOWER VILLAGE OWNER'S NAME Connie Nicholson G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL GEI PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 GENERATOR 1 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 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY 0 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 El MGF El JP 0 JGF❑ LPG' ❑ CORPORATION 0# PARTNERSHIP ❑o LLC❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsE!efwinslow.com S310N M3IA31:1 NVlld #11Wb3d $ :33d ❑ ❑ 11023d 31-11 SV S3A13S NOLLVOIlddV SIHI oN saA S310N N01103dSNI 1V1\113 A1N0 3Sf1 K1103dSNI 39Vd SIHl S310N N01103dSNI SVJ HJl0H k MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY i YARMOUTH 1 MA DATE I12/3/21 1 PERMIT ---5 JOBSITE ADDRESS 48 WILDFLOWER LANE YARMOUTHPORT J OWNER'S NAME CONNIE NICHOLSON GOWNER ADDRESS ;SAME 1TEI f7743303030 JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL , 'I EDUCATIONAL j RESIDENTIAL fit:: PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES El NO❑ APPLIANCES -1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - BOOSTER �,moo..._ _ f _________-_ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I - DRYER —Alf FIREPLACE . ' FRYOLATOR FURNACE NOTII GENERATOR 1IIIIII GRILLE 11111 MIN INFRARED HEATER 1 it IMMIIIMIE LABORATORY COCKSr r MAKEUP AIR UNIT r --- OVEN _ III Ell" POOL HEATER —1 L I ROOM / SPACE HEATER ROOF TOP UNIT A- IIIII — _TEST r 1 f �'.. �� UNIT HEATER UNVENTED ROOM HEATER II WATER HEATER OTHER _:�... _ J� Mill iiill 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 L. OTHER TYPE INDEMNITY 0 BOND _ OWNER'S 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 I i SIGNATURE OF OWNER OR AGENT o 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 complianc i a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ? ' ,......94,— `0 PLUMBER-GASFITTER NAME : STEPHEN WINSLOW LICENSE # 12298 SIGNATURE PIN O MP i vj MGF JP ❑ JGF ❑ LPGI❑ CORPORATION [I# 3281C PARTNERSHIP❑# 1 LLC ®# NM `. COMPANY NAME:LE.F. WINSLOW PLUMBING & HEATING i ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL! INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts �` Department of Industrial Accidents l'i=; p Office of Investigations Lafayette City Center _i 2 Avenue de Lafayette, Boston,MA 02111-1750 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): I.0 I am a employer with 90 employees (full and/ 5. 0 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]** 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 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 if, -tm the ins and penalties of perjury that the information provided above is true and correct. Signature: 0? --- -»ply 01/02/2021 Y 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): 1fBoard of Health 2.❑Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia