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Home My WebLink AboutBLDG-22-003831 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE January 10,2022 j PERMIT# BLDG-22-003831 fi .,i JOBSITE ADDRESS 16 NANAS WAY OWNERS NAME MACISAAC GREGORY J G OWNER ADDRESS MACISAAC LOIS S 16 NANAS WAY WEST YARMOUTH MA 02673 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 I 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY❑ BOND 0 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 0 MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION❑# 1 PARTNERSHIP ❑# LLC 0# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsnaefwinslow.com S310N M31A32i Ndld #iIWH3d $:33d 1I1/183d 3H1 Sd S3AQf3S NOI1HOIlddV SIHI oN saA S310N N01103dSNI 1VNIJ AlNO 3Sf1&0103dSNI 2:1Od 39dd SIHl S310N N01103dSNI SVJ HJl0% MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK "YAW CITY YARMOUTH I MA DATE 12128121 _ 1 PERMIT # 2 3 JOBSITE ADDRESS 16 NANAS WAY WEST YARMOUTH 02673 OWNER'S NAME LOIS MACISAAC _.____,....1 G . 1- OWNER ADDRESS SAME 1 TEL083943417 1 FAX ,,.... . . TYPE OR OCCUPANCY TYPE COMMERCIAL 7 EDUCATIONAL Q RESIDENTIAL ! 1 PRINT CLEARLY NEW: RENOVATION: a REPLACEMENT: 0 PLANS SUBMITTED: YES NO APPLIANCES 7 FLOORS—► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER -- - — — BOOSTER .__....: — — CONVERSION BURNER — . COOK STOVELONNIE'S, .,,masensoma.- DIRECT VENT HEATER I 4 DRYER ( . �. - i FIREPLACE , FRYOLATOR L. ! . _ FURNACE 1 —j , GENERATOR - I.......... -_ GRILLEsir INFRARED HEATER LABORATORY COCKS _.. MAKEUP AIR UNIT p OVEN E ir- •r! POOL HEATER _ _ _ ROOM 1 SPACE HEATER 2 - ROOF TOP UNIT r TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER1 ir . _ _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES EJ NO El I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY - OTHER TYPE INDEMNITY <; BOND [ 1 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 t.11 Q SIGNATURE OF OWNER OR AGENT 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 Zr- - Massachusetts State Plumbing Code and Chapter 142 of the General Laws. op PLUMBER-GASFITTER NAME [STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP El MGF ElJP ElJGF El LPG!ElCORPORATION E# 3281C PARTNERSHIPQ# LLC ❑# .o s.. ,� COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE J CITY SOUTH YARMOUTH STATE MA ZIP! 02664 TEL i5O8-3 -7778 __I FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM 0 The Commonwealth of Massachusetts Department of Industrial Accidents 1 s Office of Investigations Lafayette City Center 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 90 employees (full and/ 5. ❑Retail c rpart time)4 -- -- -- 6. ❑Rcstaurant/BarfEating Establishmcnt 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.ri Manufacturing no employees. [No workers' comp. insurance required]* 4.IIIWe are a non-profit organization, staffed by volunteers, I l.ill 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 policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. #1964A Expiration Date:01/01/2022 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 cer,• y-�ii�the wi�s��n—d penalties of perjury that the information provided above is true and correct. Signature: `—\ TY 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 3.11I City/Town Clerk 4.El Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia