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HomeMy WebLinkAboutBLDG-21-000614 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK ,-t CITY YARMOUTH MA DATE August 11,2020 PERMIT# BLDG-21-000614 JOBSITE ADDRESS 2 COMPASS DR OWNER'S NAME YEE SANDRA C P G OWNER ADDRESS 2 COMPASS DR SOUTH YARMOUTH MA 02664-5112 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES❑ NO El 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 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 0 JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP[026641207 TEL FAX CELL EMAIL inspectionsaefwinslow.cam 1i 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 7 -- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - -, - - CITY I /4 Ay-144.- j MA DATE[5"---Icai:i PERMIT # Be--D6- - .0?/-on (o fy I JOBSITIDRESS1,1?7, -.70_,Ligat„Os_,,_01.__50 )ill,is!,1 1 4.:1 OWNER'S NAME i r TO kV) -YFF— ---1 G I OWNER ADDRESS _ TE1431 Iltilk_Q:ux _ FAX E- 5017/c TYPE OR OCCUPANCY TYPE COMMERCIAL IT EDUCATIONAL I RESIDENTIAL! ---i------ PRINT CLEARLY NEW:L.. RENOVATION: i__ 1 REPLACEMENT: 1 ,ic-,!'-------- PLANS SUBMITTED: YESF:j NOF , APPLIANCES 1. FLOORS-) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER Y--A---•'-- - : , .. BOOSTER . t - - CONVERSION BURNER i COOK STOVE 1 , DIRECT VENT HEATER ---- !-- -- i ...._ ... DRYER FIREPLACE , FRYOLATOR FURNACE _ GENERATOR , GRILLE INFRARED HEATER LABORATORY COCKS — - MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT —1, TEST E .., ------ , , k. : UNIT HEATER , UNVENTED ROOM HEATER Pt WATER HEATER - Aija r---------- .- - - ' t Jtizo 1 OTHER ! _ I _ 0 p rArm.....:*.44..._ ,-,=-2,600.1fil.-46x,..Jt.E.410-2,ixaaltiallligglifdr,,allad4 6- ...- - 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 1:117; OTHER TYPE INDEMNITY 1 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 ! AGENT 1:- 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 accuratp 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. 1/4 ......1k1...- r--- ._, PLUMBER-GASFITTER NAME i STEPHEN WINSLOW LICENSE #1 12298 I SIGNATURE r---- ,T, MP [7: MGFI JP 1:__] JGF il_j LPGI CORPORATION r--/.# I--3281C ! PARTNERSHIP--- 7Thttr--------7 LLC 77#[ 1 , "--• %- Li. '' COMPANY NAME:LE.F. WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDON CIRCLE CITY i SOUTH YARMOUTH i STATE I MA 1ZIP; 02664 —1TEL i 508:398-7778 J cl..., FAX 508-394-8256 CELL N/A !EMAIL! INSPEETIONS @EF W.--INSLOW.COM ...._........„ 5 61) The Commonwealth of Massachusetts Department of Industrial Accidents • `1 Office of Investigations '' Lafayette City Center • �r, V 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): 1.1] 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.❑ We are a non-profit organization,staffed by volunteers, 11.❑Health Care with no employees. [No workers' comp.insurance req.] 12.0 Other • *Any applicant that checks bqx#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.#1909A Expiration Date:01/01/2021 Attach a copy of the workers'compensation policy declaration page-(showing the policy number and expirationrdate) 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: 7' 01/02/2020 Date: I 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 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia