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HomeMy WebLinkAboutBLDG-17-003518 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a CITY YARMOUTH MA DATE January 10, 20' PERMIT# BLDG-17-003518 JOBSITE ADDRESS 28 CIRCUIT RD WEST OWNER'S NAME COWLES MARK B II G OWNER ADDRESS COWLES TINA M 1023 STONY HILL RD WILBRAHAM MA 01095-2251 TEL TYPE PI'.OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRIN'I' 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 ❑ 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© MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: Stephen A Winslow ADDRESS 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES` Yes No THIS APPLICATION SERVES AS THE PERMIT❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES `; MASSACHUSETTS UNIFORM APPUUCAT GON FOR A PERMIT TO PERFORM GAS FITTII !G WORK 9. 2:" J.'. CITYryarrn_Lil_, _ � MA DATE .. ..=. 1 PERMIT# t, 17-110 9�/e ,,- -‘,,...--,-, c� ;OWNER' NAMEfp' �~��--�;--- -. JOBSITE ADDRESS' -f. > _�.' • L '� I6‘ o5 OWNER ADDRESS TO, r `T E p C-7 1C -34 3 ifiTAX. -1 tteli TYREOR OCCUPANCY TYPE COMMERC ALIJ EDUCATIONAL • RESIDENTIAL VI PRO CLEARLY NEW:[ RENOVATION; 1 REPLACEMENT:ler PLANS SUBMITTED: YES NOW APPLIANCES- FLOORS-4 ( 8SM 1 2 1 3 4_ _5 I s 17 1 8 I s 10 11 1 12 1 _13 14 BOILER ! l {I,__ _►1. ----Ill__, 1[--;_ - 1- . , II. .. .- _lei. .: . !c.—I1:.,. -�III -11I,- ---- 1-•• --.I BOOSTER - E [ I_. _ I,f. _--L. ___III. - _�-� ;•-_LJT-,!l� •IL, . •�!.. ._ .J.- .:. I ^ .I11- -- II._. I. CONVERSION II _ ' . _ _ y __..._ '- �i ^-_- `I:_. . .{[ - - - •-•- - . - • - - BURNER I. �"tll: :�!:;III: � ►- ,i� -i� �I�:���Ii=--_����.��!_ {� :_�i [� _I-II:��": COOK STOVE II_ ___ ,il, _._- 1!r.. ^1�L . .�f; _ = iV-- .. •:..,��1_ _ TI_—.�f1�..._._ .[•I . . llw., .!.I-_....i j----.[Il-_--j HEATER i - -1!------ f lT_..._(�i_�:: i__ - I_�; i� :.:l L..-- • ;I- - i�_-..._ I - j!---- 1__�.- !_ - DIRECT`VENT -�_ -_. _ „IT_ -._-._ '.��_ II-�- I� �(__�__ DRYER it `- ; r:- �- :I,I1 -= � 4L • IETET 1; .;I_-._, 1, ..__.[1r �.III-FIREPLACE 1_ l _;1_...- - l' =t'-_::_ - -_:,,_ II.. - -!!- - _:'I ._. ! '!;1 I _ill:---- i FRYOLATOR • 'I _ - 17- -.. _ •-r . .i1, ..1__;I.. '(1.=_j_.'I- i. .-I.--- -. . !, _,7 .[._.-. . FURNACE � (I�_ _ .. I!�- __ fIl- . :___[ I„ _.:__II I-__1;. .. tl_ . _Ii. ▪ tIi_`. I ___Iil._. :_lI1 -_ .III _ . .. GENERATOR - _ -.__ ..--- . - '' _-- - --- - I--. ". _ . �jI ...... ' - f_._ _ . .. I. �I.__�_ I-_ �- �1�. _�: _l I,_, _.(� ▪ i I �i- i!- !I(..2...7.1:::i ^l'I-� , _...il'�._ GRILLE i:. �.11- -- i 1z ti�. .. : .. .._ 1__ ,,! ,j I�_._� h� I __ ;�.._: ., 1� - i it., t.,- �I;i~_. INFRARED HEATER I :_. _• -_..._-_ L. -_ '_. ..1.I _._.)I - '_ - --f i~. �.,:. 1 -- i--• •l I- ----i LABORATORY COCKS • ' . . . �.I_ 1- I ��[_ F I (I . ' _ — f- _ MAKEUP AIR UNIT . • 1 f! ---- I^---.: 1 , �1-• -=id-- . IIIL_.I I I._ _�[1_J- .�I1 J'L. _l r^__i l: .._ I I�: • OVEN I,.----. . ,, ! l _. .. f ::-w(1_. y t I. ,.._11---.:.__ — s. -' .__ ;I,_ . -- _ c-Q - POOL HEATER = ' . .. . ` - I_-.. .I .` ..-' -_E •---- _• _ -. -•— -- P.00M 1 SPACE HEATER 1� ! _-!1�-_--}!a i•!,�__`�T.-. t!----.._._,jr—_,LT.. _ j 1--_,_ I_ ._ !, ._ . I_:.. 11,.. _ .f i-.-•-_• -.-.._=c v ROOFTOP UNIT l---IL . . .1 I. -.. L , i . .. _,:l-__ fl.- -i!.. ..r1'1 11. ,--I I-� f I,_ .._ fL._ .H J1. -[ (7' TEST 1. - I- _ _:l ••- !.__ ''I_ _~1!, -�.i!. ____11 .. _ .I..._.-_ =1,..-,. .FI.,._„..:I.-- �_J I_ -- - tl_ - ! UNIT HEATER ci) ___ 1_ . .__i 1�_ 1;1 __[ !. . :�,I: _ l, -,��1, . �1, _,I . ..`1 . I 1 ! , I_. _ UNVENTEDROOMHEATER I rI ... -(1 . ._,1.•• • (1:_ _ I. .-._?! 'I __ _11 _ _ 1---'I. _['1, . _J!_ -I11. -- N�_ WATER HEATER. .-.r__'z__ 1�— i_ I .. 1,1.. j! I: _I�— ,!— :..[,; _ L. I i I _I �_i OTHER 1 ._�.. . :.__._... _ _ __._ 'E. �!:� ... !�_')1 .I!_ I I.___ I �._ _ :L ------I;1._.___"__::-..1 F._ 2-)1--_,.:7,1;17.--1 E.....---:!17__—___-! I__ ...if I=_::_i : !_`—._ I-�-- -L =- 1:=:-=-.-r:_T11iITiTiTTli : — .•Y- INSURANCE COVERAGE I have a current liabilii insurance policy or its substantial equivalent which meets the requirements of MGL, Ch,142 YES I!rl NO Li I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY Li BOND LI - 0 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. U • CHECK ONE ONLY; OWNER J AGENT Frii 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 compl' ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I-STEPHEN A.WINSLOW __ II LICENSE 1229 I SIGN I UR • • ---^ '�' CORPORATION ,, # , MP I. MGF1.—i JP�� JG1=�;i LPG!I� �-= [3-2-8,1C-„il PAP�TNERSHIPL� �„M�_�._ci LLC��,-�' . . � , ... r.. - COMPANY NAM Ei EF WINSLOW PLUMBING &HEATING _ I ADDRESS, 8 REARDON CIRCLE :.- -.�,.� CITY SOU T H YARMOU T H _, x M _ • ?664 E -394-7778 ` STATE MA �Z[PI C7 1.-cam_ .. - �•::�� �—ems t_..-�=_i �, �-.`___.^_�...=._.__.....J++_.—.--��_-t L �J 0 8 --- .._.--.-e.-.r——__ .........a..rx...a ...aY-e___.u-._.-.. FAV „�08-39�'.-825fi �ii C>;LLrN/A !`EMAll�accounispayable@ei�yins[ow,com...,.. : ._.�..,v_ ...�...._.��,: .., „_. .,�.,.rr.,:��,..-.�...,�.�,.,.�_::;' 4, e) U , • J tie 4 • 3 49rww mars'sgov«iict a,h + • Workers'Compensation k_suranee Affidavit:Builders/Contractors/Eleetr dianslEta anlbera •Applicant Information i q Please Print Legibly .• Name(Business/Organization/Individual): 5 • ,r 5t,,,, l!7�y~we{ 2 �t 4.iklz i. 'tic_ (�rtl Address: gs tks > -�CI • j City/State/Zip:. So,3-rf\ j e��mcs t-, 4-; Phone#: 5,Y6.3 9,17- ' • . Are an employer?Check the appropriate box: Type of project(required): ;,,'4 I am a employer with '70 4. ❑ 1 am a general contractor and I 6 0 New construction employees(full and/or part-time).* have hired the sub-contractors ;.❑ 1 am a sole proprietor or parter- listed on the attached sheet.? 7. 0 Remodeling ship and have no employees These sub contractors have 8. 0 Demolition n \ workers'comp.insurance. _ \J working for me in any capacity. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 4.❑I am ahomeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions [No workers'comp.myself. c.152,§1(4),and we have no 12.0 Roof repairs insurance required.]t. employees.[No workers' 13.[Other comp.insurance required.] Icy applicant that checks box#1 must also fill out the section below showing flick workers'compensation policy information: • . Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. ;ontractors that checiethis box must attached an additional sheet showing the name of the sub-contractors and:their workers'comp.policy information. am an employer that is providing workers'compensation insurance for iny employees. Below is thepolicy and job site t ormrction. tsurance Company Name: b UJ c k i n,'t ,.)u''c&n • :llv- ' .<fL3 , .olicy#or Self-ins.Lie.#: 1 ai I ¢ • Expiration Date: —[ o )b Site Address:a3 c�`'t"P 0 ; C yr il' 1 11 City/State/Zip: C),)LA( 7 .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under•Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a tie up to$1,500.00 and/or one-year imprisonment,as well as civil penalties inthe form of a STOP WORK ORDER and a fine ['up to$250.00 a da againstthe violator. Be advised at a copy of this statement may be forwarded to the Office of wesfigationstrof the DIA.for insurat • overage ve earn.. i. do hereby certify uncle 1the1ains ands,penalties o[ .jury that the information provided above is true and correct. l t 7 I P- ; ienatii e _ . _ -`` �" t Date: (DI_,,{ t + hone#: : l'i,-' r. '7X Official use only. Do not write in this area,to be completed by ciV or town official City or Town; Permit/License# Issuing Authority(circle one): 1.Board of Reallth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector G.Other Contact Person: Phone ft° .