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HomeMy WebLinkAboutBLDG-22-006952 -; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 01,2022 PERMIT# BLDG-22-006952 ll =• �t JOBSITE ADDRESS 14 BOWSPRIT PATH OWNER'S NAME Cindy Hodgdon G OWNER ADDRESS 02158-1411 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL Ill 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 0 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 ❑ JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(v7efwinslow.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 T �� A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ''-ail! - =tea" 1 CITY .YARMOUTH(WEST) J MA DATE 5/25/2022 PERMIT# Qri- JOBSITE ADDRESS 14 BOWSPIRIT PATH,W YARMOUTH,MA 0261 OWNER'S NAME [CINDY HODGDON GOWNER ADDRESS 6 UHLMAN DR,WESTBOROUGH,MA 01581 J TEI (978)505-1186 IFAX I ] PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ( RESIDENTIAL TYPE OR CLEARLY NEW:0 RENOVATION:til REPLACEMENT:IA PLANS SUBMITTED: YES D1 NO APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i.. 4 BOOSTER _�- , 3 CONVERSION BURNER . .,,- I _ .�-1 `° „ i.: _ Nit COOK STOVE 1111111111111011111.1a11111.111, � r DIRECT VENT HEATER l - DRYER I ti.' i 11 FIREPLACE __- FRYOLATOR FURNACE — : 1 1 _ r GENERATOR ._MIMI ;M,: GRILLE i 1 1 I,_ .�.:i f_ m_ _ INFRARED HEATER � , 1 - LABORATORY COCKS MAKEUP AIR UNIT i _ �� OVEN POOL HEATERS ROOM/SPACE HEATER ; TJ I, �— 41 1 ROOF TOP UNIT TEST ii": . „..„„,,,,L, .i., - t I ,r.-- -..i'r: ' ,,i- . -- ,,a,: iiin, ligiant' UNIT HEATER UNVENTED ROOM HEATER �� ' i WATER HEATER l � i OTHER ! r _._.''@ _..: ligimag Rf ;4 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO Li I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY r BOND El 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 Lj AGENT LI 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 b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc a rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ 11 -. .-...1....- PLUMBER-GASFITTER NAME ESTEPHEN WINSLOW LICENSE#€12298 SIGNATURE MP . MGF 0 JP UJ JGF LPG'1:1 CORPORATION[]#13281C PARTNERSHIP�e i#r LLC 7 # 1 COMPANY NAME EE F WI NSLOW PLUMBING&HEATING ADDRESS 18 REARDON CIRCLE ,— m. _ __ 4 P „_ CITY SOUTH YARMOUTH STATE[ MA 1 ZIP[02664TEL 1508-394 7778 FAX[508 394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW COM - __.. The Commonwealth of Massachusetts o ; Department of Industrial Accidents 4 Office of Investigations 72 Lafayette City Center Cry 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.ID I am a employer with 99 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restauranti ar/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. El 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]** 11.1=1 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 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:01/01/2023 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 ' er the ins and penalties of perjury that the information provided above is true and correct. )7//- � 12/01/2021 Signature: 7' 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 30 City/Town Clerk 4.1:1Licensing Board 5❑Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia