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Home My WebLink AboutBLDG-23-000724 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '1, CITY YARMOUTH MA DATE August 11,2022 PERMIT# BLDG 23 000724 JOBSITE ADDRESS 23 DUTCHLAND DR OWNER'S NAME Roland Brierly G OWNER ADDRESS 23 DUTCHLAND DR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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 El 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 El MGF El JP El JGF El LPGI El CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(atefwinslow.com S310N M3IA321 NVId #1IIJ 3d $:33d ❑ ❑ 1111213d 3H1 SV S3A?J3S NOI1VOIlddV SIH1 oN s8A S310N N01103dSNI 1VNId A1NO 3Sf12J0103dSNI NOd 39Vd SIH1 SALON N01103dSNI SVO HDf10d MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE 8/8/22 PERMIT # 23 - 0 7 Z.. JOBSITE ADDRESS 23 DUTCHLAND DR, YARMOUTHPORT, MA I OWNER'S NAME ROLAND BRIERLY OWNER ADDRESS 'SAME I TEL(508)364-8539 FAX, TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES ` NO APPLIANCES -1 FLOORS—i BSM 1 2 3 4 5 6 1 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER ;` COOK STOVE DIRECT VENT HEATER DRYER f FIREPLACE ,, FRYOLATOR FURNACE GENERATOR I GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT �I OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER.....FIRE PIT { w u s INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES v NO L. . I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 f 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 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. Y PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP MGF JP JGF LPGI CORPORATION v # 3281C PARTNERSHIP # LLC # COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY [SOUTH YARMOUTH j STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 : CELL NA .� .REMAIL INSPECTIONS@EFWINSLOW COM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations (' io Lafayette City Center k ,t,:t 2 Avenue de Lafayette, Boston, MA 02111-1750 i_ 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.❑ 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 ' e the ins and penalties of perjury that the information provided above is true and correct. r ^� ��- Signature: 0 Date: 12/01/2021 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 3.1:1 City/Town Clerk 4.❑Licensing Board 5.1=1 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia