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HomeMy WebLinkAboutBLDG-22-003647 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e' `-9 CITY YARMOUTH MA DATE December 30,2021 PERMIT# BLDG-22 003647 1/47: JOBSITE ADDRESS 90 BRAY FARM RD SOUTH OWNER'S NAME Carol Nicolora G OWNER ADDRESS 90 BRAY FARM RD SOUTH YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL al PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 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 GENERATOR 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ 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 LPG! 0 CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionst7a,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 UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,1yn- ' :1il CITY YARMOUTH I MA DATE 12/16/2021 PERMIT# - - 3 C. Lt JOBSITE ADDRESS 90 BRAY FARM RD S.,YARMOUTH,MA 02675 OWNER'S NAME CAROL NICOLORA I GOWNER ADDRESS SAME I TEL(617)593-2066 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW:El RENOVATION:Li REPLACEMENT:L3 PLANS SUBMITTED: YES® NO APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER NMI � NM 1111111111111 MI NMI BOOSTER iiiillirillit • • I i 11.111111.11.11 1 MN am am inn mai aim DIRECT VENT HEATER j�f .. - nn DRYER a RR FIREPLACE n in, n annunion FRYOLATOR i- � --ililifilligliMINII INFRAREDGENERATOR OM NM MI MI NMI INN NMI 1111111,0111111,NM 11111111 NM IIIII IIIIIII IIIIIII GRILLE Ma ' • ,, ii, , III l i LABORATORY COCKS MK INK 1111111111111MI MK NM MN 1111.1111111[11111,01111111111111111111111 NM NMI MAKEUP AIR UNIT 1111111,10111 MANIm 1l nalair On '1 `O OVE ••• M 01 M MI •• SPACE - I ;1 ill TEST UNIT HEATERlimmilimarsimilitiliglallitillillitaIllitilliMir UNVENTED ROOM HEATER MIIIIIMM1 I :' . 1 . 1MME i OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LI NO Lj I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIAiTY INSURANCE POLICY OTHER TYPEINDEMNITY t - 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 0 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 accurat to the t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian a YPprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 71 d/ • /� I. -• ,.1- PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 ' SIGNATURE MP U MGF LI JP L3 JGF El LPG'Li CORPORATION Elit 3281C PARTNERSHIP D# 3 LLC El# COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA IZIP 02664 ----TEL 508-394-7778 FAX 508-394-8256 CELL N/A jEMAIL INSPECTIONS EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 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.® I am a employer with 99 employees (full and/ 5. 0 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. [No workers' comp. insurance required] 8. 0 Non-profit 3.0 We are a corporation and its officers have exercised 9. 0 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, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.0 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:01/01/2023 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 ce f/of the ins and penalties of perjury that the information provided above is true and correct 12/01/2021 Signature: r "` '`''-�' 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): 1.0Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia