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HomeMy WebLinkAboutBLDG-22-000763 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Gj 6 CITY 'YARMOUTH I MA DATE August 10,2021 PERMIT# BLDG-22-000763 JOBSITE ADDRESS 6 HIGH GROVE RD -I OWNER'S NAME TIGGES JOHN L G OWNER ADDRESS TIGGES ANTOINETTE M 122 WEBSTER ST NEEDHAM MA 02494 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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 1 FRYOLATOR FURNACE GENERATOR 1 GRILLE 1 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: [iTEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsna efwinslow.com • S310N M31A321 NVId #lI N 3d $ 33d ❑ ❑ 111,0,13d 3H1 SV S3A?J3S NOI1VOIlddV SIHl oN saA S310N N01103dSNI 1VNId AlN0 3Sfl 210103dSNI 210d 30Vd SIHI S310N N01103dSNI SVO HOf1021 c MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =:.ins CITY R I MA DATE ,, PERMIT # 2Z — --/G7 ti JOBSITE ADDRESS t .49 i OWNERS NAME /V/ _1_G 5 GOWNER ADDRESS 14-,9-?--kiG fe."�- 5/ Pit.i/h�/� TEL ���• 77'0 7 4_,FAX____,....___,,,I TYPE OR �� �,.._x_,_._.. PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 1-1 RESIDENTIAL . CLEARLY NEW: RENOVATION: L_ REPLACEMENT: l ; PLANS SUBMITTED: YESO NOLI APPLIANCES -1 FLOORS—* BSM 1 2 1---3 4 5 6 7 8 9 10 11 12 13 14 BOILER i BOOSTER ; ., il $ I CONVERSION BURNER _. COOK STOVE DIRECT VENT HEATER -- L _ . UMW l - 13 ...- .„ DRYER FIREPLACE _L FRYOLATOR I I1 —_FURNACE M : _ -_ ' - GENERATOR /_.....IM ,-. — -) ! . .,. _. GRILLE < INFRARED HEATER LABORATORY COCKS , _______, , ., . ,_. . __„ , „i pp" , MAKEUP AIR UNIT , 1 OVEN - -- POOL HEATER ---- --- 11111111111111.11111111111111M11.1111111111itiiii ROOM / SPACE HEATER 111111111.11111,1111111111111111111111111111111111111111 ROOF TOP UNIT _ ' ,..0 , 1 TEST - UNIT HEATER , - _ n- UNVENTED ROOM HEATER _ 1 �Till WATER HEATER n_ ';._ .. . C - 1., _... ! 1111111 OTHER - - _ �M -----iiiiiiiiiii'' mi giiii . illi-111111111111111111 IIIIIIIIM-WI , _ _ __ VIE .., .... __ 44 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [j NO ri I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 12j OTHER TYPE INDEMNITY 0 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 and that all plumbing work and installations performed under the permit issued for this application will be in complianc 1 a PPrtine provision of the .). . Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ r 'cJ, N PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 1 SIGNATURE '---..., MP i MGF ._r_.,J JP ❑ JGF ® LPGI 71 CORPORATION 01# 3281C 1PARTNERSHIP # LLC .1111. Lk , COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 I FAX 508-394-8256 1 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM e Ry The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a Lafayette City Center 2Avenue 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 90 employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar mating 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 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.❑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.] 12.0 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: 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 c •f}y-sere e the phins and penalties of perjury that the information provided above is true and correct. f� Signature: "~ �-' 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): 1❑Board of Health 20 Building Department 30 City/Town Clerk 4.El Licensing Board 5FJ Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia