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HomeMy WebLinkAboutBLDG-21-004238 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - ` CITY YARMOUTH MA DATE January 29,2021 PERMIT# BLDG-21-004238 JOBSITE ADDRESS 157 WHITE ROCK RD OWNER'S NAME TULLIE DONALD J G OWNER ADDRESS TULLIE PAULA S 157 WHITE ROCK RD YARMOUTH PORT MA 02675-2385 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO En FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 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 1 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: T'EPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsta7.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 UNIFOR M APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t -off, ; CITY v+v wto� �(n r.,.,_„ MA DATE[1.1.112 ( _ 6 /-6 U y� JOBSITE ADDRESSI LU1 rL - ,a �r/�r��hi oil' , OWNER'S NAME pu U1 )Irc G OWNER ADD RESS TE �S C��0 Xr....-L...= TYPE OR --„ � „ Z FA PRINT OCCUPANCY TYPE COMMERCIAL u EDUCATIONAL 0 RESIDENTIALE- CLEARLY NEW RENOVATION;L1 LA REPLACEMENT: PLANS SUBMITTED: YESO NOD APPLIANCES -1 FLOORS-► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1 BOILER -----I I - .. 4 BOOSTER 1.172 r ._ �. �. __... .y �1 -7T:::_. ' I. .- 1 I 1 _ I�.. ;,, ��"3 I - ''1 .I a `�1 1•'' "^.Il .- _�....;� • - ----i — ��.d..�. ,�incv.:.,e�r-r>vfi 1,.........j � �1) , 11 CONVERSION BURNER L ��� � �� ; _ �-- - I. __.,� .____ ( _._.� __. '� ...... 'r .�). .R.-..�. COOK RSIO 1 ;.. _- " 1117 __ ) _ ;I^.,_. �r 71�.. .. ►1:.: .. 11 . . I ."__ Imo, , � DIRECT VENT HEATER � r:—... i�[,_.-�.. .1. - ..,.a1 �.,-�-� - F . . . 1-.SL . ;;�_���1.~ .._ '�-�Y. _ ..'I���.� '�. '��� �F ._ �'1 . ..,M' DRYER �! ..�.. _ __ � - --� I` 1_ r�.. ii l �11 _ � � �'17117�_ -.ti .. � �, FIREPLACE 1s._ .,I..__..._.,.�I_.�...._ i .. _-... __..� _�._I��.. .I.. ► --�����_�� __ _ 1771 I. _ _�'I. .. ;�_►1 I.-__� =-' F -� ; . - _. _ ;If. I-�- , 1 --_-d ". 1- 1-- f_ . I.I_ ,__ . 17. ►f7. -- _I FURNACE � •�; ----n-� -� __ '� ____-- r1--�. �:� �- ,,F.- ,1 ^_._l1lm.� 1I�._ .. �1� . ���I. .�1 ._ _,l __if II GENERATOR ---- '1 f _ ._ '1 . ._._ .r_�_. ._ �. .� .- •�- �-.... :�1��_ .� .I. . ' I.,�__, I_ - . h GRILLE --_.�� = F �-= •,-=- � .� _ ._ 1J -_jh_ �' _ 'I E I_ _ INFRARED HEATER _�,:��, t1Y- ---.1'1 . -'-_ ' C .. _' t I- �iiF"_- 1-1 )Cp + 1 . r. : I, 1 .a.. 1 l� 1 I( 1 _,.^. 1 �Il rl C r-r - �.Y1 LABORATORY COCKS �"''� _ °1- . ,�. I. .—_ � . r�.�' F_�. ��1�" . :� �; I� �(. �-_.. - .�f� -. �� _� i..,. .�F I ----d ''17.-- F . „1 —4.F_ -.-I I� 7.., -- -- 7 . _ MAKEUP AIR UNIT EL:;� , .�.. 1 v -- __.- . r.._- -- .... _ ,_. ' _�_� -=-� -�,.� - ..� .1 J-�' f .. _..r l.. 11 I� ►I� _ OVEN �...._.�,F.._.: ,�;l_ : _ ,; ..� .�,F�.� _;, -.v.. Y 1... . r I �-_�1 T ��,I - .l I� -�I! a 1�T... _111" �.:I I ^_ . _►) OVEN HEATER 1----- �' � � F�_�., - � I1 I W 11. I;I II{T~�- II It�� . �i 1-�,1.� ,_..111 �7I xT.n. I.. 1---.Ti, I ,r .f I,. 1.� .l1 1,'_..:_ ..�1- II I- . .� 1- --�l.. J r r-_—ROOM 7 SPACE HEATER "'' �_� �' --_ . � - . _ - � _ - ._� _ _ . _ ;. L -.V �I'I-1 ►1 it[_.. _li : . Ti L-- _I F- I �':1 ,JI___. 'r. ,;v -� __21 ROOF TOP UNIT �� r T ._._� x - -a. . _._ .._� _ _� 11_���.F-_-_. �___ --,.I__-_�� TEST .___ _ _ .,IT ..-`f . ,. 1 (:.. .�__. _ E74 - - E177 UNIT HEATER L-tea,' 1 _� _ 17 _.. .......3- - �11 _: 7x.. C- .., 1� `Il� i - 17 II.; 7- 1 _ - -11 IT--,". I . �I I . 1 L 7 I. 1 _7 �. .� � _ in._ UNVENTED ROOM HEATER I.. _111 . . �1. --. �i .�ii T ._ �' _ ..�. - -. .� 1��. �-111 ..11 ._T.:I l ., �11' ~��.�� T��_� 'I 1-~ -..II WATER HEATER ,�... I_ . i -- ---_ 1- __...y:;I �� 1 �l',l .II ITT;- ..��f�• _ _ 11.--� ��_ �,I� I'(� �_ i - OTHERi- �...; �..4. . . 1 _-.� ' -- '1 �11 ' f 1. - .' ""l. - _ . 1 a__ T. �1 ..,-`1 ,11,-7,---7-7,)c.-7.-21;i:T.,:-...v.---.,-.-,. -:iirT::1,- L,.......,,..,=._,,,..„,=,,...,_,Jr.----r- . __a _r-r-r._, �1:::-. `is_ 1. .�= i1 -. .. . 1 t..-"717 1- .----4-- _ 1 �,.-..., f` _ 1fT- o.'7[7. ' _, 11i "I1.- .I ,I J( 11 _ _ ' I` ' 1�-� 1, � �f_�I)It I FM1 . ���` Ir 1. rl 1._ 1 1.. 4 r!I s . 'l �,I ""„err - 1, 1 a. 7. -- 'liTi; INSURANCE COVERAGE -. R -E ,_ ti " " I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. h. 42 YES .� " I NO { I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BYCHECKING THE APPROPRIATE BOX BELOW JAN 2 o 202 fi I LIABILITY INSURANCE POLICY L` OTHER TYPE INDEMNITY ' --.-- ..z.:..____I 1_ _ • is DEPARTMENT OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required bit4fraperf142--iyhtpazd Massachusetts General Laws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER „ AGENT El I hereby certify that all of the details and information I have submitted or entered regarding this application are true and and that all plumbing work•and installations performed under the permit issued for this'application will be in complianc accua tPt rtine the b st of my rovi on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. P the PLUMBER-GASFITTER NAME[ TEPHEN WINSLOW �J LICENSE #7222-9-8 I .,._.,� SIGNATURE ' MP .�I MGF��(] JP JGF� LPGI I' CORPORATION �!A# 3281 '6"---1 'W�3 -"--�- Nor-_,, _.._v� w_ __. ". "..�W. PARTNERSHIP( I�# �.. _ LLC M]# Z COMPANY NA w_. .�." '"`-, - ' ` _ ME. E:F, WINSLOW PLUMBING & HEATING ADDRESS[Ii-li-E-ARDON CIRCLE _ CITY (SOUTH YARMOUTH J STATE MA ZIP ... •µ•ry L I02664 .._.._. . -_ 1TELEaEioji„.........„.w.a... FAXL508-394-88256 1 CELL N7Ar�Y JEMAIL1NSPECONSSLOW.COM e� The Commonwealth of Massachusetts Department of Industrial Accidents 9 i- r---1 s Office of Investigations j Lafayette City Center j 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): 1.0 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, 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 8. El Non-profit [No workers' comp.insurance required] 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]** 11.❑Health Care 4.0 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#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.Lie.# 1909A Expiration Date:01/01/2021 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 cert. a the ins and penalties of perjury that the information provided above is true and correct. / 01/02/2020 Signa ture; -if .... ,....4._.M 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): 10Board of Health 2.[]Building Department 3.0 City/Town Clerk 4.ElLicensing Board 5.0 Selectmen's Office 6.[]Other Contact Person: Phone#: