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HomeMy WebLinkAboutBLDG-23-000183 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE (July 12,2022 I PERMIT# BLDG-23-000183 1L_ JOBSITE ADDRESS 77 TAFT RD OWNERS NAME ROSE JUDITH E G OWNER ADDRESS 77 TAFT RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0 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 ❑ 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 State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP©MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionst7aefwinslow.com S310N M31/132i NYld #JIINHI3d $ :33d ❑ ❑ 111183d 31-11 SV S3A1:13S NOI1VOIlddb SIHl oN SOA S310N N01103dSNI 1VNId AlN0 3Sl 210103dSNI 210d 3OVd SIHl S310N N01103dSNI SVO HJf102' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ®u 1 - CITY YARMOUTH ' MA DATE 6/28/22 PERMIT # 2-3 -- , i k JOBSITE ADDRESSL77 TAFT ROAD W YARMOUTH MA 02673 OWNER'S NAME [JUDITH ROSE G OWNER ADDRESS � 77 TAFT ROAD W YARMOUTH MA 02673 " TEL�-5082378986 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL J EDUCATIONAL 1 RESIDENTIAL i__ I PRINT CLEARLY NEW: , RENOVATION: 1REPLACEMENT: El PLANS SUBMITTED: YES Ti N0-1 APPLIANCES -1 FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ BOOSTER L. _- „ CONVERSION BURNER COOK STOVE _ DIRECT VENT HEATER ,. ..T,,„, .�__ DRYER FIREPLACE _ FRYOLATOR ;i - - l _.�... FURNACE 1 ,^ 1 II GENERATOR T,..:.-- � I___ - - — GRILLE —11I ._ .. INFRARED HEATER -11 IF .._ .. 1 1i. _ LABORATORY COCKS MAKEUP AIR UNIT - _ _ _r_. L:_ ! —_ OVEN _ II. — POOL HEATER ii ROOM I SPACE HEATER ROOF TOP UNIT I -- _____ _ , _ 1 _ TEST 1-- - UNIT HEATER UNVENTED ROOM HEATER _ - L :: _____. , ._ WATER HEATER OTHER _ _—. I I i i -__-__ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES LI NO L. I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1 " i OTHER TYPE INDEMNITY j i BOND p___ 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 LI AGENT Ei 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 a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ r 004444.• PLUMBER-GASFITTER NAME I STEPHEN WINSLOW LICENSE # 12298 H SIGNATURE MP El MGF .. ..,i JP 1 JGF LPG' CORPORATION i 1# 3281C ! PARTNERSHIP # I LLC Ll#1— ---] P. `) rv\. COMPANY NAME:] E.F. WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDON CIRCLE J ^` ^ CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 v L FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM l. The Commonwealth of Massachusetts Department of Industrial Accidents _' �_ T Office of Investigations "' = 1.— Lafayette City Center •.=t4 2 Avenue de Lafayette, Boston,MA 02111-1750 l.'s 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): 1.111._lam a employer with. 90__ employees (f ll and/ 5. ❑ Retail or part-time).* 6. E 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.] 12.111 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-his. 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_S 25A�fMGL c._152 can lead to the imposition of criminal penalties of f 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): I.❑Board of Health 2.0 Building Department 3.1=I City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia