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HomeMy WebLinkAboutBLDG-21-004451 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `k,_? CITY YARMOUTH MA DATE February 05,2021 PERMIT# BLDG-21-004451 JOBSITE ADDRESS 9 EDWARD ST OWNER'S NAME BRENNAN STEPHEN A G OWNER ADDRESS BRENNAN JEAN M 9 EDWARD ST WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III 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 1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 ❑ JP 0 JGF 0 LPG' 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsRefwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK v iliW- �`II�= CITY Ic4 L- MA DATE 12 ( PERMIT # 0-1k4 • �•�_ / �is��uya� tolALIU va'� J / i- rs/�1 : OWNERS NAME s JO(5BSITE ADDRESS,��.:� r ;� ������� ����1 �,,,,�1?�Y►� �i �n�r�idl _. „. ,._ GOWNER ADDRESS vl/t I TEU p y `h7 �� r 7 6 ,FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL; EDUCATIONAL ' RESIDENTIAL L_., CLEARLY ��� NEW: 1 RENOVATION: REPLACEMENT: I_~. '" PLANS SUBMITTED: YES NOD APPLIANCES -1 FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER t.,..... .: . BOOSTER .� ,,..;.... , CONVERSION BURNER _ 1 COOK STOVE - i DIRECT VENT HEATER i DRYER � 3 ._ - I, ____ _ __ FIREPLACE FRYOLATOR �,. 1 37,1 .. . ,_--- FURNACE I- , _- ! _.�_� . ._ _ ;10— _ GENERATOR __ ii GRILLE i I` _-_ _ i INFRARED HEATER i 1_ _ LABORATORY COCKS MAKEUP AIR UNIT OVEN ___• __ , POOL HEATER ? ____ _. ROOM I SPACE HEATER ��e... , ROOF TOP UNIT 1_ ( f — E• . — UNIT HEATER I__ _ I I _ ._. .,__ @- UNVENTED ROOM HEATER �� _._ __ . ' _ 1 WATER HEATER OTHER i i . __..-. f ._ - - _ .... . i:(tliivdwi.W+...watt:54YtRai'NtCR14Y6i;4U:i[GV::ffw:wti�^ru5' IQYYi'kFti:<A6lkYYYF•e"•........•..-w,ur'd`4a-1Yei4u1L•.,•.......• , INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES IA NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY s / OTHER TYPE INDEMNITY Y _ 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 u AGENT 1... 1 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-GASFITTER NAME I STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP ill MGF 1 JP 1,11 JGF LPGI 0 CORPORATION I ✓ i# 3281C 1 PARTNERSHIP! : Tl 0 lV COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS ! 8 REARDON CIRCLE 2 8 2U� .__ _— �- CITY [SOUTH YARMOUTH 1 ST,ATE F MA]ZIP 102664 � TEL 150g-394-7778 I —. BU+LUING DEPARThArNT .-....; FAX'. i CELL NIA JEMAILI NSPECTIONS@EFWINSLOW.COM BY:__ The Commonwealth of Massachusetts 9— D, ..„,..... „ epartment of Industrial Accidents AIM Office of Investigations Lafayette City Center f 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 90 employees (full and/ 5. I❑ Retail or part-time).* 6. ❑ 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 required] 8. [1]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]** 11.0 Health Care 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#I 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 ' 1e the(/ s and penalties of perjury that the information provided above is true and correct. 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): 1.0Board of Health 2.❑Building Department 3.❑City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia