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HomeMy WebLinkAboutBLDG-22-006611 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE May 17,2022 PERMIT# BLDG-22-006611 JOBSITE ADDRESS 226 KATES PATH VILLAGE OWNERS NAME John Ryder G OWNER ADDRESS 02668 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 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 ❑ 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 pertormed 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 I LICENSE# 112298 I SIGNATURE MP©MGF❑JP❑ JGF❑ LPG' ❑ CORPORATION 0# PARTNERSHIP 0# 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(defwinslow.com S310N M3IA321 NV1d #iJW2i3d $ :33d ❑ ❑ 1114183d 3H1 SV S3AN3S NOI1V3IlddV SIH1 oN seA S31ON NO1103dSNI 1VNI3 A1NO 3Sfl 210103dSNI H03 3OVd SIHI S31ON NOI103dSNI SVO HOflO I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k. CITY YARMOUTH I MA DATE5111/22 i PERMIT # L ti JOBSITE ADDRESS[226 KATES PATH YAROUTHPORT MA 02675 OWNER'S NAME JOHN RYDER Y w - I __ GOWNER ADDRESS 211 MAIN ST CUMBERLAND ME 04021 ___...1 TELL2078293646 FAX .__ — , ._ TYPE OR OCCUPANCY TYPE COMMERCIAL S EDUCATIONAL fA RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: El REPLACEMENT: 0 PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ r BOOSTER _ . CONVERSION BURNER ,` ,1` r lilt- _ COOK STOVE DIRECT VENT HEATER DRYER _ . FIREPLACE _ -- FRYOLATOR T . FURNACE 1 I r.. GENERATOR GRILLE _ INFRARED HEATER LABORATORY COCKS i - ...- MAKEUP AIR UNIT - OVEN � _-Allo... „ POOL HEATER . .�.. .... - ROOM I SPACE HEATER ,�..,. ,. ,. . _ ROOF TOP UNIT TEST �_M ..hmagii UNIT HEATER �. ftsuge,. - UNVENTED ROOM HEATER — - — .. - 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 v NO 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 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 accurate to the b st of my knowledge -40ft 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. 0 ? ' /(l'""'‘' */'`.'- ,\ PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE -^ �" MP N 1.:.,t MGF JP J JGF ElLPGI El CORPORATION �1# [3281C PARTNERSHIP®#L LLC 2#�—� COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING I ADDRESS' 8 REARDON CIRCLE CITY SOUTH YARMOUTH 1 STATE MA ZIP[92664 ITEL 508-394-7778 1 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS©EFWINSLOW,COM =-7r-- The Commonwealth of Massachusetts I Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 "" ',''ys 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. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ONon-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.❑ 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 police 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 cerof rn e.the ins and penalties of perjury that the information provided above is true and correct. �� , p�,� 01/02/2021 Signature. �' 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 2.1=I Building Department 30 City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia