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HomeMy WebLinkAboutBLDG-21-003741 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE January 06,2021 PERMIT# BLDG-21-003741 Itsmit �' JOBSITE ADDRESS 22 MUSKET LN OWNER'S NAME LEPORE OLGA M TR G OWNER ADDRESS LEPORE REVOCABLE TRUST 22 MUSKET LN YARMOUTH PORT MA 02675-2127 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 GENERATOR 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 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 El BOND 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. 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❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsefwinslow.com U — S310N M3IA33d NVId #111V:13d $:33d ❑ ❑ 1IW213d 3H1 SV S3Aa3S NOI LVOIIddV SIHl oN saA S310N N01103dSNI IVNId AINO 3Sfl 2l0103dSN1210d 3OVd SIH1 S310N N01103dSNI SVO HJl021 • . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Aitif.ff' CITY 1.....6=2L/... 7 MA DATE[ / LE PERMIT# BeA- 4371 ..,„. ,.,,:... JOBSITE ADDRESS 1 a IA e !' di 4i(moda, /0,4 02/0 1:OWNER'S NAME GOWNER ADDRESS L.„„..a0a,..,. . JTEq2.2,3,ozFAXL.....j. TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL ET RESIDENTIAL PRINT 'LEARLY NEW:0 RENOVATION: D REPLACEMENT: rji--------- PLANS SUBMITTED: YES NOD 'DPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 104 11 12 13_ 14 i JILER 17771---- -11--.7 - --.7.. -1 _ 117-7,..,.,...77:17„.71[7.7,..7.1 00STER r1451 ,I ONVERSION BURNER 1._,...21-- - r- .- '. I - - -II . ----- r--- --.11----11 711171-.(-11-. 300K STOVE -7-. . ___---71 .I- - -.:I -. il ' - 1 .-ir -- V. ' li - . ,.I - 11- 4- -- _ I-- ---.:1-.7---!1-----7 'IRECT VENT HEATER _71::::';1- - .;,I - --':I - -- 11--- ; 1 -4 . il . 1:1 ---11- - -11--- ';[. .-- 11----J - - 4----11 fiYER 17,7111-----11 - - lj-71F-71-71771.7711-77i 1-711.---T n 7 -II.-:::::1.7. Jr. -___,Ii' IREPLACE L...,,..:1-- -Tr-- - 4---. --;,1--- ---. 1---- 71--- :1 - q---TT- 4-_--- --T- :7;17.7.7id-:_ 1--,-7.,_-_-,1 Fpvf- - cr@ r----11-7. ---.::1--7!17-11-----TT..-1.1----1--7.11-7-11--7.117----ir----1E711. .... f.i to - - , c-) . 1 -- --11 -7-II ------I---11---177117-4.--711-17-71.-1--. . -G-ENCRATOR I-. -- - [ 1 - 1- - - -.I __.'1. I __ [ __. . I: ' :!1. 7 ...d -- _ . r - 17717:77:11711:17 .ii GRILLE I:,..,-D1- ' -HI- TI-- ----4 - ----1 17 ' 7 . 1.-----.1:--.-.-_:-.-iir- --,---!w•- --;1177-711-.:- --0-----9------T. T.-3 INFRARED HEATER 1::::::11.---- 11-Tr-- ---Ar:-7.--: r 7-7. 1.---,Tr.---.--. T .4-711.- -----;r- 7 .--.77-77-7-1r --.---', LABORATORY COCKS E=1--- ..- 17 -_---71.- LT-I- -771:771.-- --1F-1---1. j.---.71-7711---.1.1.17.7r 77.-: MAKEUP AIR UNIT 7 .1,----D I - -i t '-- -4 -- - -IF - ----iir.-------; [-- -47 -_-----11:7 ---;i,1•_---: OVE N 1=17.:Din ---.- r----1,1-------7 fl- ---.11----d-POOL HEATER HEATER =. 1 ----771----7, 1-----'1-71----.71---.-1'17-11-711-70--771----71-----"--.F---.---..ii-t-.---;1 ROOM / SPACE HEATER 1..._,J Lill .r1:72It.C.. --7._ 11: --..-..-.-J17_711:717. .-i.ETJETT:=7.1 ___77:1-: 17-_,-; :_-_..r.771 ROOF TOP UNIT 1 : j1-7-TI ---:! -..---- -1711--- -.:1--- -11- ---1117,17711- TEST =TT-F. 7 177.T.1-17,1- .-7 7.--. .17---717-71777i17-1- -I-Tr 71 UNIT HEATER I if --!.,1-- Jr- -----4-- --I-7 1 ---7i r---7-11- . .------- ------..: -- ---1---7 -- . -iii - 1 UNVENTED ROOM HEATER 1-- Jr-:- --I • --:: -1-1- --- 4--- - - - ..r -7.1 - --i,i- WATER HEATER F-717-i'r------- r-----7[7- r--------. 1.---7.-s,T:17 .:r77.777.77-ti):-. 1OTHER , . 'l'------1:!---1. ---11---11 - -T1- --- --',F.- -71-- i:- -di -L:All -,____ ii11-1:: ..... ...... _,Ji„:„:,,,:i •:c7= 1[ _. - 4: - 7 r.--71 -:-. 7.1--.----_- :-- i_,:-70' 1' -1 I :31 _ _ :...______,=:_ _ --- 1_ _- 1____-_,A-- j . .:1 .2 . • -H,47,441,,,,, ,._. ..... „.4, 1.1.,._ 11. . .. j__...,,,.,,,...;...„.„._ . jil il - --- -if------d--- ' - ;1.-- -----; f----i,I-A-7. --;!r. -.-ET."1-77r°1#171A77.7,11cAt NT,. - T--• INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES El NO 0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY rij OTHER TYPE INDEMNITY LI BOND [A 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 ro AGENT ri SIGNATURE OF OWNER OR AGENT \_t? 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 worIcand installations performed under the permit issued for this application will be in compliancya Pirtine provision of the : S-. Massachusetts State Plumbing Code and Chapter 142 of the General Laws. rofi. ......"---- r.., PLUMBER-GASFITTER NAME 1 STEPHEN WINSLOW j LICENSE #112298 I SIGNATURE (---‘, =_- MP 0 MGF 0 JP 0 JGF 0 LPG!D CORPORATION Eal# L3_281C71 PARTNERSHIP Ell#L____ _i' LLC E.I#E. ,3 \ nr\ „..._ ,..•.......... ....•••••••••••1.1.••••••••••••••wa.........r•••••••w••••-•-•-•nvr..,.........W. IA COMPANY NAME:I E.F. WINSLOW PLUMBING & HEATING ADDRESS FliiARDON CIRCLE --- _ _-----1 1.1.. k--1 CITY I SOUTH YARMOUTH --- --- STATE[TVIA-1ZIPI. 02664 JTEL 508-394-7778 FAX I 508-394-82561 CELLILLI/A EMAILEVSPECTIONS@EFWINSLOW.COM ___....._.................____............_...................._ S;. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 7 : -. lj Lafayette City Center j 2Avenue 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:g REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer? Check the appropriate box: Business Type(required): I.El I am a employer with 90 employees (full and/ 5. ❑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. 8. Non-profit [No workers' comp. insurance required] 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]** 11.0 Health Care 4.0 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: i 909A Expiration Date:01/01/2021 Policy#or Self-ins.Lic.#' 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 cert' i the ljins and penalties of pet jury that the information provided above is true and correct. � 1,0 , / 01/02/2020 Signature: ,.."'`� Date: Phone#: 508-394-7778 Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 1.0Board of Health 2.0 Building Department 31:1 City/Town Clerk 4.LILicensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: