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Home My WebLink AboutBLDG-21-002045 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK te rra CITY EARMOUTH —I MA DATE October 19,2020 PERMIT# BLDG-21-002045 JOBSITE ADDRESS 111 WHARF LN OWNER'S NAME Mike Sherman G OWNER ADDRESS 111 Wharf Lane Yarmouth Port 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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❑ 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 0 MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: ETEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX ]CELL EMAIL inspectionsAefwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ El FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK, "......XS-f"-.-..-.--•• i i 2....Witi-:73 ----..-...-- .--___._.____,------1 ..,_...-...........-_-........ 1 CITY LYfk.,..,")' 1-,1 0,pc74 MA DATE .r... L(8.4L,42;f:)., : PERMIT # -',2) •1 --V-4 •.4:-'77,7. 4 - _,11-.,----.:-...., a • sumue•-•••••••••vmeenaw . wevaca....,......• . .-, JOBSITE ADDRESSialgi. ki/ '__...Aw- OWNER'S NAME PIT7-7371erm.44 1 ..„,. ...11..4„1.....' .4. _ .,....,2 G OWNER ADDRESS 1 5uia-t — ' liTEI,ri)---$No q a 1 Y .-1FAXE-----1 TYPE OR PRINT OCCUPANCY TYPE COMMERCIALE.] EDUCATIONAL !_11 RESIDENTIAL CLEARLY NEW:El RENOVATION: 0 REPLACEMENT: 1::: PLANS SUBMITTED: YES El NO11 APPLIANCES -f----. FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i....: '. .1-.7-7.'[.:-.DIIN17. T. 117-3 17,.1-:I--.1----___ ril------... 1.77::::;1-.._:-T12.21 : 1-1. ..-i IT_ -77 I-----.-_-.:' BOOSTER r-_ -_JI--T'r:—IIIIIUT.--- -' I----li- -71 - ---,11------lr-711-"-----Tr----- r--- --;i---,r ! CONVERSION BURNER II l' ."--1 F--:-_'-'1 --7iii717r.-.7._71-7-- li-.771i17-.. .-11-..--. -..J-7... ..: 1-1.--.7' , 7 COOK STOVE 17,-_-___A -_-_- -_:[_-:-,-Lrf_i_ 1-1-- I__. :If -.:--_-4-: :-... ":1-:,ii -::..74:iiii.:-.--::: 1_ : .. fl- _,_ DIRECT VENT HEATER ----7 —1471 ti , Iiii ----_--ci- A-7 1-- Pi _.." 7-: 1_ T ---. DRYER [7:-.1 -_,:::„.:'l-D;l::_-._-_'", _-_-_-_-,: l'il _-_:.-.4,-:--.--ii: .....:-.1) -.:_i;E-..-.1,-J1-1 -.j1 --_-_:-.71-:._--Jr=11:_. FIREPLACE I . --- -.9.-----il '.1.---.-----! 1 .. -ill111- I',1..T. -.-7-I I--- :i --------I1 - -7!i---- "TuRnFRYOLA-1 , ri -17- II _ :IN .177•117 ,-,1 Li:: .T7_317 . .,--ii _ ii __ _ ITT- [ __. _it __tr. . _ 1 —vff'-----------T- IF- •;:i- Wm I--- -111--.4-7701._. . iT----: _ ll------7 '11 GENERATOR 1---1.7.. if777t. . .. l• --7-: '..........._________1111MINKNoimr--, — -_----i GRILLE - -.D1:71-1117-111-1! _11.110ffiguminil-f„1111.. .___..111;-.1,7-21:1._li INFRARED HEATER 1-___11 . . I'r7:-lf-T._._......________MIIIItliffillilla-7 :11 —7 — , 1-----1f 1 17 -Ili--; LABORATORY COCKS 177---i,It-:::7d7::: -T:7 milkunlimummil - .--2: . _ !;! ---,-, .-:. 1.1--_-_._,...d ._._. :11_ 1..---71 MAKEUP AIR UNIT I --D ----'' .k ---111111111.11101M1 --711----7Ir. -11 - 1- --III 771171:; OVEN i____. 177.-' F.:-. 17.7-ii _ . 7-7-,i17-2-i:1,--71-7,771'17-.7.11:::.-,17, POOL HEATER I-..,.. r..-I 1-_l_..-ii i . ,....Y.-7 o:_-_:: LIT 2'ii-_=,-d..".--:17,.-_-_-:.1._=.„1,.-_-: : -,1-_-_ -_, I__,..-71L.- !.1--_-_-___:. ROOM/ SPACE HEATER , _.,,.i . : -. I: - ;I -17i1 1.---(11._-_. ...f -ir.-,----71-----,:il-- 17111- II Tr --T 1---11 ROOF TOP UNIT 1. =II.-_--._ ti 1:=7:1: -_- -:. _--- , -----1 i---ii- -11---7-- 1 =T1HE _ j I : ITEST f - - - -- - 1 - --- UNIT HEATER --T_ __ : 1-.7----1 --..--17_ ._ i .:-...- T----.iir--4-1--:::117----1-- - -in_-_--f-i-TA- -I UNVENTED ROOM HEATER — _11---7-' r----7 -- .'inivrimm_whi_wiimm....._,__________------ V-----7 7r-4- i--Hr-n 1 .71-1 ir--:-..-1---- - __„ vvA.L-ER jEATER _ ., f._ 11 '1 i 'imminiumiuffi ___. OTHER], 1:--. ---7r ---- 1117-11 -__--11. -----d----11-7 I . ---.11----117.--, 7-7.11- 4-77r -TIT-sr fl y: - - -• ,.T--_- „ .!.1-: -id -1'i-.-:- , :! 11 .- .I1- • Ti - -.-.1,.1 ---. . i!]ii--- rd.1 - . ...JId1. 7'41 . • . f1 -- ' ,.1 --.,I-- ; i- - : ----q----, 1-- ' 1----:.1----1!---71--- 11-4---1----TE- -1 r--- INSURANCE COVERAGE r...._, I have a current lial_JBLInsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES El NO L J I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY Ch ECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [7] OTHER TYPE INDEMNITY ITT! BOND I: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 r;:::1 AGENT 1--_-_-. - (--) ________________SIGNATURE OF OWNER OR AGENT z-- I hereby certify thaoririi.i detas and infonine submitted or entered regarding this application are true and acourat to the b st of my knowledge — and that all plumbing work Eind Installations performed under the permit Issued for this application will be in compliarn P/rtine provision of the Massachusetts State Plumt frig Code and Chapter 142 of the General Laws. ' / !.p r 1-s- PLUMBER-GASFITTER NAME . STEPHEN WINSLOW )1 ' LICENSE #L12298 1 SIGNATURE MP 0 MGF El JP {-_‘__J JGF 1 ] LPG!ril CORPORATION E.:1#112_11..2._11.1- PARTNERSHIP 1.:1#[ j LLC (111#I . -- ___ _ (4 COMPANY NAME1 E.F. WINSLOW PLUMBING & HEATING21 ADDRESS FRTAIRDON CIRCLE -------- .1"" 4.0.•••••••••asarta.m...wmiseac.......,,..1...... tf CITY SOUTH YARMOdTH — —1 STATE —1v1A7ZIPFC12664 _ITEL r5a8-394-7778 ' ----- ' FAX i 508-394-8 CELLEEMAIL:Ii\TS-1";i6T16-N'SiP-FWIR1-SLOW-COM---- — • ------------ ____L______ID Nr:: DE p."..,-- t The Commonwe, lth of Massachusetts Department of'ndustrial Accidents 117. 1 Office of nvestigations ' Lafayett' City Center �' 2 Avenue de Lafayette,,Boston, MA 02111-1750 www. ass.gov/dia Workers' Compensation Insu ance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: E.F. WINSLOW PL MBING & 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] I am a employer with 90 employees (full anti/ 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 ha e 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunte:rs, 11.❑Health Care with no employees. [No workers' comp. insurance rig.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below show ng their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation h.s 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 nsurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURAN( E COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins: Lic. #1909A Expiration Date: 01/01/2021 Attach a copy of the workers' compensation policy decla,ation 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 o this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' the ins and penalties of perjur that the information provided above is true and correct. Signature: 01/02/2020 Date: Phone#: 508-394-7778 Official use only. Do not write in this area,to be compl.ted by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1•❑Board of Health 2.0 Building Department 3.11 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: mace any/din