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HomeMy WebLinkAboutBLDG-22-006566 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r'7110-1 CITY YARMOUTH I MA DATE May 16,2022 PERMIT# BLDG-22-006566 JOBSITE ADDRESS 14 MAKEPEACE LN OWNER'S NAME Sharone Petrone G OWNER ADDRESS 14 MAKEPEACE LANE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL Ei PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS BSM 1 2 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 ❑ 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:he 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! ❑ CORPORATION❑#L PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX 1 CELL EMAIL inspections(efwinslow.com S310N M31A32!NVId #11142:13d $ 33d ❑ ❑ 111,11?Ed 3H1 SV S3A213S NOI1V3IlddV SIH1 oN se), S310N NO1103dSNI 1VNIH AINO 3Sl 210103dSNI 210d 3OVd SIHI S310N N01133dSNI SVO HOl021 , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 11°`"T..1019 ' , Ck'SWIZTA CITY YARMOUTH J MA DATE 513/22 1 PERMIT #_ 'Z Z 6 5-(06. JOBSITE ADDRESS 1T4 MAKEPEACE LN WEST YARMOUTH 02673 OWNER'S NAME LSHARONE PETRONE 1 GOWNER ADDRESS liaLN VALLEY DRIVE BRAINTREE MA 02184 1 TEL 77814246366 IFAXL TYPE OR OCCUPANCY TYPE COMMERCIALE EDUCATIONAL RESIDENTIAL 71 PRINT CLEARLY NEW:fl RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES® NO0 APPLIANCES -1 FLOORS-4 BSM 1 2 3 4 5 6 iii 8 9 10 12 13 14 BOILER IllitillMN _.._ 111111uni` .. BOOSTER MEM P Will CONVERSION BURNER inuoiontle moo MIEN COOK STOVE r 111111MI 1.111MMINIII IIIIMME DIRECT VENT HEATER MIIIMMINIIIIIIIIMINII 1.1011111111111111= DRYER 10111.111_ 101111IMMIIMII 11041111111M0m FIREPLACE FRYOLATOR FURNACE =II ' GENERATOR . _-1 . 1 .1 GRILLE Polemilijillirlinellinl . Ili INFRARED HEATER 11'111.111111111 illiMmuliwililillaill 100111 — IIM LABORATORY COCKS WIIIIIIIIIIIIIIIIIMMIIIMINOM � MAKEUP AIR UNIT OVEN 111111M11111 111:1111111 -1.--- NMI POOL HEATER NM= _..,,_. _ s I, ROOM / SPACE HEATEREl II ROOF TOP UNIT MININIPIrildir TEST :I M UNIT HEATER __ UNVENTEDROOM HEATER 1.111111 1000— - Mr RN ININIIIIIIIIIIINT WATER HEATER MIIIIIM 11M111111111111111.110•1111011 — Mil OTHER r-- _ .,_ .1111Ms•W MI IM IIIIIIMPill MAE MEM REF NMI '�.. -.. . . mit �_,.w.r.._u. Mill.._..........:1 ..:h 41.D a . . ,_ INSURANCE COVERAGE I have a current liabil y_insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES I v NO Ej I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v OTHER TYPE 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. CHECK ONE ONLY: OWNER AGENT O 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 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 rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ? --- ,6/,.,.-1.--- PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP v MGF JP JGF ( LPGI CORPORATION v 1# 1-3281C PARTNERSHIP , # LC ®# -FT-. i....... s' COMPANY NAME:I E.F. WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDON CIRCLE 9 rN. - - �' CITY I SOUTH YARMOUTH STATE MA ZIP 02664 ITEL 1508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM i n � r The Commonwealth of Massachusetts jq— Department of Industrial Accidents Office of Investigations lift Lafayette Lafayette City Center . 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): 1.0 I am a employer with 90 employees (full and/ 5. ❑ Retail -- -- - or part-time).* - - 6. D 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]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *My 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 ce ' e the ins and 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): l LjBoard of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.❑Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia