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HomeMy WebLinkAboutBLDG-22-000762 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,�.' 4 CITY YARMOUTH MA DATE August 10,2021 PERMIT# BLDG-22-000762 !i JOBSITE ADDRESS 11 SANDPIPER LN OWNER'S NAME MARINO GENE TRS G OWNER ADDRESS MARINO RUTH G TRS 499 CASINO AVE CRANFORD NJ 07016 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 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 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT , OVEN _ POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 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,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER OF INDEMNITY El BOND 0 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 0 LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX 1 CELL EMAIL inspections(a,efwinslow.com S310N M31A321 NVld #1IIN213d $,33d ❑ ❑ 11W213d 3H1 SV S2Aa3S NOIIVOIIddV SIHl oN saA S31ON NO1133dSNI 1VNI3 VINO 3Sfl d0103dSNI 210d 30Vd SIHl S310N NO1103dSNI SVO HOl0?J _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 ., j CITY • MA DATE J 1, ( _.I PERMIT # ZZ-- -7 Z- JOBSITE ADDRESS r.I.\. 46,11.. _C... a___- cYWI ✓ --_..._,.._ti. OWNER'S NAME t�eili.. ,i�r .�. . ..._. ,._...__._. . _ ... .._..__..;. GOWNER ADDRESS !:1...$1..9.. u-5! _,ItvG ,.Ct,(6�.,;�Atr._Q..1_..0.�_,_ , ---_.1 TE_ 7p1, -.. .. .1... ...... ...w._...y.+FAX __. -.._._.. I TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION: Li REPLACEMENT: PLANS SUBMITTED: YES 0 NO LA APPLIANCES -1 FLOORS--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER .-._.,._.. .-- r ...v FI)_---.---- 1 -.. _---L----0------- ' --.-,- . -.. ..-_.-11t----- _ --._-.w._ ._—A1-._ .1. .-- -_w_..._111_. _.. BOOSTER CONVERSION BURNER 111111111111=Willallifin. COOK STOVE DIRECT VENT HEATER M f11111111 DRYER _ FIREPLACE ve/Nrc E jllraill I( _ ..__? _ ._..... , 1111.:-- W1 _ i.IR FRYOLATOR T --. - _1. ...-' - r� - t �� _.r' _ -_ FURNACE .. ....._ . r a k 3 GENERATOR - fi t GRILLE _..-- ----.1 ----- ---- __..- --: ..-__...__I ------� ._...__�1------; -- - - - --- - - -- _ - ---. 111 INFRARED HEATER _,...._,..M_ ! ,.,.___-..,.j....._.-.....,.,,1).---_T,..1-...__ _.! . .........._.0 - _.' _.___1 .. - z „ LABORATORY COCKS MAKEUP AIR UNIT11111111111.1111.1.01.1 OVEN - 111 POOL HEATER ROOM I SPACE HEATER ' ROOF TOP UNIT moutimitaiMMAffimi -= -:Jijiiiimea TEST L._ t __.. f . - -A ____ ' _._-- UNIT HEATER tl __...__. UNVENTED ROOM HEATER - _ . __ .__ ._:.. _. _ .' .. _:_ WATER HEATER M _... -___ .._ _ . 1-__._.._._. _J _. !`E .._..__... -.__-. ____._.;1,,_. ._ ._ I_. _._._�1-__:___.__` _ ___. .____ __y _ 1 - OTHER �-Y-! I E _. 1 _..- - _, _. . _. . �--1-77-; _..�=�.-� I-- ---- -- .: - s '. _ - I ' ___. ' •••••-•.x...----..._..-...i:Y...".:1Y:2'J'.1W0i':A=.Silti�:,• __k -. • - -- _ _ - _, __ _ _: _ _ v 1111111111111.11,1111111111111111111111111=11.2_ T. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 0 NO Li I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1771 OTHER TYPE INDEMNITY LI 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 [ w1 AGENT f 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 st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliant i a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r "� ..s. IL_ PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP Lj MGF LI JP 0 JGF 0 LPGI [ CORPORATION a# 3281C PARTNERSHIP E#_______: LLC U# __ _______ COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY [ OUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 3 9 ti FAX 508-394-8256 ] CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM Z The Commonwealth of Massachusetts Department oflndustrialAccidents nirt= Office of Investigations -"61= Lafayette City Center _a. 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): 1.11 I am a employer with 90 employees (full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. El 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 10.11 Manufacturing no employees. [No workers' comp. insurance required]** 4.ElWe are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp.insurance req.] 12.111 Other *My 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-pot cy-dtclara`ion 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 er the s and penalties of perjury that the information provided above is true and correct. ,f/ , J Signature: f' - `^-r 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): 1.0Board of Health 2.❑Building Department 3.0 City/Town Clerk 4.El Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia