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HomeMy WebLinkAboutBLDG-22-002806 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK " CITY YARMOUTH MA DATE November 16,202'PERMIT# BLDG-22-002806 JOBSITE ADDRESS 52 WHITES PATH OWNERS NAME CAPE GRANITE LLC G OWNER ADDRESS 19 QUINCY AVE OUINCY MA 02169-6709 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL v❑' RESIDENTIAL❑ PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO El 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/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 0 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 I LICENSE# 12298 SIGNATURE MP©MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP El# LLC❑# COMPANY NAME: 'STEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR, CITY IS YARMOUTH I STATE MA ZIP 026641207 TEL ' FAX I ICELL EMAIL inspections(1a.efwinslow.com I S310N M3IA3:1 NVld # LI1AN3d $ :33d ❑ ❑ 111183d 3H1 Sd S3AH3S NOI1t1O1lddd SIHl oN saA S310N NOI103dSNI 1VNId A-NO 3Sf1 H0103dSNI IO 130Vd SIHl S3LON NOI103dSNI SVD HJf102i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i`"arm '-_"• - CITY 'YARMOUTH (SOUTH) MA DATE11/09/2021 I PERMIT # L C JOBSITE ADDRESS ..._ -.�,._._� � __ .-...w�... .. _�....._� ._...._.- _._.._..__�.w ._ ..�. 52 WHITES PATH, S YARMOUTH, MA 02664 OWNER'S NAME GRANITE CITY ELECT SUPPLY, INC. OA►k ,4 t _.__._ _ .. _.... ...,.. . OWNER ADDRESS 19 QUINCY AVE, QUINCY, MA 02169 l TEL 508-394-1262 IFAX 1 TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL v = EDUCATIONAL RESIDENTIAL .m CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - BOOSTER CONVERSION BURNER to COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 2 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER Ir ROOM / SPACE HEA-ER M ROOF TOP UNIT T3- TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE M I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ; v NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 Li AGENT Li SIGNATURE OF OWNER OR AGENT 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. , �,�r PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE #i 12298 1 SIGNATURE MP MGF JP lj JGF LPG! CORPORATION v # L3281C 1 PARTNERSHIP u #, I LLC LJ#L COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS ` 8 REARDON CIRCLE _ �.. 1 N\J CITY SOUTH YARMOUTH I STATE MA 11131 02664 TEL "508-394-7778 , FAX 508-394-8256 CELL NIA !EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 9f Office of Investigations tw Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 „(k_ !1 wwx.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. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.11 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.IIIWe 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: 1' .........4... 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.❑Board of Health 2.0 Building Department 31:1 City/Town Clerk 4.❑Licensing Board 5 fJ Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia