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HomeMy WebLinkAboutBLDG-21-004429 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =_` CITY YARMOUTH MA DATE February 04,2021 PERMIT# BLDG-21-004429 JOBSITE ADDRESS 11 ELTON RD OWNER'S NAME IBAKIS PETER G OWNER ADDRESS 297 BELGRADE AVE#2 ROSLINDALE MA 02131 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III 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 2 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 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. 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: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL I EMAIL inspections(a)efwinslow.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 ;=?_All CITY /�? ,� MA DATE �� Z(� ,,ewy PERMIT # x_. z� ,.:mu�:.ssu+u..u..u�.sa�vawnirsr::au�u.,�..a.;u:a.-oaa,;,.r:wuar...a�casa+rasac'„zaaa:ex��.wsr.:m:aw.w•..scu:.� a. .. wK. �ra�t,�:c�.avwaaaa:Gwc a-. JOBSITE ADDRESS i1 rti-v, k a,v4/4t� L65 1 OWNER'S NAME Pf &u,1ri,.'„�.,, ... ��� I GOWNER ADDRESS LI 1 6 LN,r-Ail AJJj u vZl�( TEL C; t' 3 5 L z Z FAX[ .�.._... TYPE OR OCCUPANCY TYPE COMMERCIAL1-1 PRINT EDUCATIONAL ! RESIDENTIAL ;( - CLEARLY . NEW: RENOVATION: . .. REPLACEMENT: PLANS SUBMITTED: YES!_> . NO ' APPLIANCES -1 FLOORS—* BSM 1 2 i 3 4 5 6 7 8 9 10 11 12 13 14 BOILER --- ,_ _ _ w__ _ -_.- -- BOOSTER I CONVERSION BURNER t._. y ' COOK STOVE , • DIRECT VENT HEATER I - i. DRYER - , FIREPLACE . _ FRYOLATOR g_ l ! _. .__ ._ ' - -- FURNACE J- i ___- .I GENERATOR i GRILLE l R t � INFRARED HEATER • i� __. -- - - LABORATORY COCKS • i • MAKEUP AIR UNIT i_.__ I OVEN POOL HEATER 9 ROOM / SPACE HEATER :...,_. _ ROOF TOP UNIT .t_ TEST UNIT HEATER ...__._�_ �. . ��_r__.�. ; _.Y. _ •_.._ 1 UNVENTED ROOM HEATER i ...... , � � 1 __________.,______. . _______,......_________:...,.. ...___ WATER HEATER i OTHER € �, - ' _ �� `1 ..1 ..__� • INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES L] NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1 i. ' 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 0 AGENT SIC NATURE 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 1 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 r- Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFIT--ER NAME STEPHEN WINSLOW _.__.I LICENSE 4122981 SIGNATURE v MP (_ / MGF I-1 JP JGF 71 LPGI I--1 CORPORATION �,,:i# 3281C PARTNERSHIPI # _. LLC # _ ; k� COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING I ADDRESS L8 REARDON CIRCLE - --- CITY . SOUTH YARMOUTH 1 STATE I MA ZIP 02664 TEL 508 '''..4 'ip: C - .. ..--� FAX i 1508-394-8256 CELL N/A IEM SPECTIONS@INSL0W.COM 2 7 2421 .1 Mi ,..1 •-, - -----NG GEPA�Ti�ENT The Commonwealth of Massachusetts Department of Industrial Accidents a warr--9 _ Office of Investigations =pr .., l�l= Lafayette City Center L. 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: I Business Type(required): 1.❑■ I am a employer with 90 employees (full and/ 5. ❑ 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. ❑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.ElWe 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 ��(/..-Apl� 01/02/2021 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): 1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia