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HomeMy WebLinkAboutBLDG-22-001315 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 7 ' BLDG 22-001315 yw CITY YARMOUTH ] MA DATE September 07,202 PERMIT# JOBSITE ADDRESS 2218 HEATHERWOOD OWNER'S NAME Anne Armington G OWNER ADDRESS 2218 HEATHERWOOD YARMOUTH PORT MA 02675 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 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-GASFITTEF NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX 7 CELL EMAIL inspectionsna efwinslow.com S310N M31A321 NVId #11W213d $:33d ❑ ❑ 111%13d 3E41 SY S3Aii3S NOIiV011ddtl SIHI oN saA S310N NO1133dSNI 1VNId AlNO 3Sfl 210133dSNI NO3 3OVd SIHl SalON NO1103dSNI SVO H`Jl0?J MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'r �I CITY MA DATE ./ l ' PERMIT # 22' l .1 I I JOBSITE ADDRESS 2 Z 1 I-lek , )eQ4__.......Ci . 2. ..,..,.-..a OWNER'S NAME 7iia-eArnii_... .... .A- ___._.__,.-..-..,.__ __.1 G OWNER ADDRESS 5oyw e, tom.01,441 N ri- . ; TE.. 40 .*W,- 5 L� A ........._...._._..._..._r ., NFX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATION 1 , 1, RESIDENTIAL .....: PRINT CLEARLY NEW: ._-.,.;, RENOVATION: ._-; REPLACEMENT: ia- PLANS SUBMITTED:• YES NOEJ APPLIANCES -1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER f.._... ._._ BOOSTER - J, — ► _ � !' r - r , . . : ,: ...._ a ri CONVERSION BURNER illi l _ __._....__ .._ ,..._-.._. ._ ...._ -- -.- .. --,- .-. . .....-_.---- • COOK STOVE 1,. _______ , ,.„ ' _ DIRECT VENT HEATER _- l I j DRYER .... { FIREPLACE _ __ - -_ — ---- - FRYOLATOR _._., E ' 17 -}._--�-� ,..~ i FURNACE _GENERATOR ,1 __,I_.-,-- - -- _ _ I ... -. - - GRILLE C .. _ -� — .-- INFRARED HEATER ;_ ,.ter ;+�._.� 1 -._. + - {1_ ', --- ______I __ ___.I - - .. �; LABORATORY COCKS ..._._t . _ ..' .___.,,: I _____. ____.,..1!•I w , . - --.._.. . ... -.....`MN --.....__.1 MAKEUP AIR UNIT ______ __,____.1.___,... .______.i __-_-.-_.... .__., _._._. 4...__-_.! __ - -- - --_.___J j_____.__T -- r-----_ __- OVEN ._;._� ._.._I __-- .; .._ .. - -_ - - POOL HEATER ( I I , .. .._....,.a _ 1 • ., -` 110111110011110111.1111.11. ROOM I SPACE HEATER S -- mut . .:_ ._. '� L .- ..__... �I ._,.--_.. I - -1011, - ROOF TOP UNIT : .-_ __._, - - -— -' - ii TEST ______,jluogitpgmigdIIIIIIIIMIIIIIIIMIIIIIIIIIIIIII. UNIT HEATER l__-' li i _____. UNVENTED ROW R ATER �- ��_ __- � .. ,L�� -- --- .- ..._ . .: � - WATER HEATER -=--r_ AMR 1111.1.1111.11MM-711.111M OTHER _-_-__...,3 ' _z �-�1 _ _ ". - - - ___I._ li x__.•,.,---."ca ._-.._.:.. -.,—�.....,......_..._...,.._„_.._..._. `- ._.__. _ -_ - - MI 1 ' 1 3 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES E.. NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW v LIABILITY INSURANCE POLICY ,_ ...' OTHER TYPE INDEMNITY BOND L..__r VN. . 44 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 Fil N SIGNATURE OF OWNER OR AGENT b — 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 cJ and that all plumbing work and installations performed under the permit issued for this application will be in compliant i a P rtine , provision of the ,s Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t f PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE L' MP .J 1 MGF ______ JP 0 JGF LPGI . . J CORPORATION # 3281C PARTNERSHIP __--,' #L I LLC # COMPANY NAME:[:.F, WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 1 FAX 508-394-8256 1 CELL N/A EMAIL INSPECTIONS©EFWINSLOW.COM The Commonwealth of Massachusetts Department oflndustrialAccidents �: Office of Investigations _ ! '1 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 phene g.508-394-7778 _ Are you an employer? Check the appropriate box: Business Type(required): 1.0 I am a employer with 90 employees(full and/ 5. ❑Retail or part-time).* t p 6. ❑Restaurant/BarlEating?s.ablishment 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 10.0 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 cer' e the ins and penalties of perjury that the information provided above is true and correct. Signature: Y '-%- 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 2.0 Building Department 3.D City/Town Clerk 4.[]Licensing Board 5]�Selectmen's Office 6.[]Other Contact Person: Phone#: • www.mass.gov/dla