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Home My WebLink AboutBLDG-23-005593 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE April 07,2023 PERMIT# BLDG-23-005593 JOBSITE ADDRESS 51 COVE RD OWNER'S NAME ONEIL ROBERT G OWNER ADDRESS ONEIL MICHELLE 6 ANDOVER COUNTRY CLUB LANE ANDOVER MA 01810 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 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❑ 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 L JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: [STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR.8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 02664 TEL 5083947778 FAX 1 CELL EMAIL inspections(7a.efwinslow.com S310N MIA NVld #11W213d $ 33A ❑ ❑ .I1A1H3d 3E11 SV S3A213S NOI1VOIlddV SIHl oN seA S31ON N01103dSNI IVNId AINO 3Sfl 210131dSNI 210d 30Vd SIHl S310N NO1133dSNI SVO Hof O I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK zom CITY YARMOUTH I MA DATE 4/4/23 PER At4r PC . 13 -69d „. JOBSITE ADDRESS 51 COVE ROAD OWNER'S NAME ,ROBERT O'NEIL OWNER ADDRESS SAME1 TEL 978-886-2662 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z 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 GRILLE INFRARED HEATER LABORATORY COCKS • - MAKEUP AIR UNIT OVEN • POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST 1 — UNIT HEATER UNVENTED ROOM I-EATER WATER HEATER OTHER : *-4M �:. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES LJ 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 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 i a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER-GASFITTE R NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP MGF JP ED JGF 121 LPGI CORPORATION7# 3 81C PARTNERSHIP # LLC „ # COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508- • FAX 508-394-8256 CELL N/A JEMAILFINSPECTIONS@EFWINSLOW.COM ..... •:i:: ..'S Al x. ..:. 'dM;.vtwYIGQI.SUfl SNG.va S.w.xw S(4wxu.4M #utvS 9uNx&5,4I$'ul .#+ti.U1'�'.u`.A.. . APR 0 7 2023 BUILDING DEPARTMENT By. The Commonwealth of Massachusetts Department of Industrial Accidents b=: 9 Office of Investigations il, Lafayette City Center WivW 2 Avenue de Lafayette,Boston,MA 02111-1750 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 120 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. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance require. 8. ❑Nott-profit 3.❑ We are a corporation and its officers ha exercised 9. ❑Entertainment their right of exemption per c.152,§1(4: and we have 10.1=I Manufacturing no employees.[No workers'comp.insurance required]** I1.❑Health are 4.❑ We are a non-profit organization,staffed by volunteers, with no employees.[No workers'comp.insurance req.] 12.0 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:23 COMMONWEALTH AVENUE City/State/Zip: CHESTNUT HILL,MA 02467 Policy#or Self-ins.Lic.#2019A Expiration Date:01/01/2024 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' e the ins and penalties of perjury that the information provided above is true and correct. f 01/01/2023 Signature: Y"" 4.. 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): In-Board of Health 2.❑Building Department 30 City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia