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Home My WebLink AboutBLDG-21-007202 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 10,2021 PERMIT# BLDG-21-007202 JOBSITE ADDRESS 15 HOWES RD OWNER'S NAME MISIASZEK PAUL M G OWNER ADDRESS MISIASZEK KATHLEEN A 1396 MAPLE HILL RD CASTLETON NY 12033 TEL TYPE OR OCCUPANCY TYPE COMMERCIA_ 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 El IF YOU CHECKED YES,PHASE 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 tie insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. St3NATURE 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 Plurrbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP❑ MGF El JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: [STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(7a,efwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes Na THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES K\-• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =4401 CITY foirriA0 MA DATE 6 ..q PERMIT # JOBSITE ADDRESS) 5 14 ovv,,c5 & Yet 1 Z ViL4 OWNER'S NAME ) aqfrzieee. GOWNER ADDRESS 3...q /L, 14; Gas Fie 44k41TE 1./6 1/5 0 7,3 FAX , TYPE OR 11(1 3 '5 OCCUPANCY TYPE COMMERCIALS EDUCATIONAL RESIDENTIAL IC PRINT CLEARLY NEW: , ., RENOVATION: ri REPLACEMENT: PLANS SUBMITTED: YESD NOEI APPLIANCES -1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ; _ _ __; _ BOOSTER I 11 11 11 CONVERSION BURNER L_- - . ,11111-11— COOK STOVE - - -• .... . . I.............. ......... DIRECT VENT HEATER - - - DRYER - ___1 — FIREPLACE t, FRYOLATOR MI - - FURNACE 11-717-7 1111 GENERATOR I_ - - - LF.. - -- - GRILLE _ INFRARED HEATER 1_ - - J U .1 U U U ii - - LABORATORY COCKS _ . 1 „ MAKEUP AIR UNIT J - - - _ - - - - - J.. 11 OVEN _ _ . . . , , I POOL HEATER I I U. t ' r ROOM / SPACE HEATER . - - ROOF TOP UNIT Mini F7 1. _ - - TEST , _ t_ _ - - I . - - -- - UNIT HEATER j _ ._ _ J. . - 1 - - UNVENTED ROOM HATER INN _ mwomums, mei WATER HEATER - ------ - - 177 - -VS. _ OTHER • MI 'lilt - -- - j _ ' _ 1,_ , • . 1 - " • • - 1 I •1.1 - • INSURANCE COVERAGE I have a current liabilAy_insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Ed NO E I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY I BOND Li 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 11 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 a rine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP Li MGF Ej JP Ej JGF LPG! ri CORPORATION [11# 3281C PARTNERSHIP LI# LLC [21# %-"•• COMPANY NAME: . WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDON CIRCLE s•t v` CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM ...- The Commonwealth of Massachusetts Department oflndustrialAccidents i==_'2 Office of Investigations - _war— 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.❑l .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.❑ We are a non-profit organization, staffed by volunteers, 11.11 Health Care with no employees. [No workers' comp.insurance req.] 12.❑ 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 e the ins 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): 1iBoard of Health 2.0 Building Department 3.1=1 City/Town Clerk 4.❑Licensing Board 511 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia