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Home My WebLink AboutBLDP&G-18-006991 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK —� CITY/TOWN SOUTH YARMOUTH MA DATE 06/04/2018 PERMIT#/,OP'/1�"et c4 ( JOBSITE ADDRESS 43 PINE GROVE ROAD OWNER'S NAME JOE QUERCIO OWNER ADDRESS 167 WACHUSETT STREET, BOSTON, MA 02130 TEL 508-760-4937 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL[r PRINT PLANS SUBMITTED: YES El NO[' CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:[� FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E' NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY vg OTHER TYPE OF INDEMNITY El 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 ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are t 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 co lance with all Pertinent provisionvi of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��t/ PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 - - SIGNATURE MP[T JP❑ CORPORATION M# 3281C PARTNERSHIP❑# LLC❑# COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayableL efwinslow.com WORK ORDER#474589/ PERMIT FEE-$40.00 Ltfl (lb / 7 �C Department of Industrial Acceaes it'-' nt Mk=`t Office of Investigations e_!= 600 Washington Street • Boston,MA 02111 s www.mass.gov/tiia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name(Business/Organizatioalladlvidual):e'c•W,,nS(ow Q(Usn6O i✓.4 a_v`t.01,- , 0., r1c Address: g Q.e ` C�rer.2- a • City/State/Zip: So Ah ivr a•-••cs..t-i, NPr Phone#: 500-399-117S1 Are you an employer?Cheek the appropriate box: Type of project(required): ,,VI am a employer with 70 4.0 I am a general contractor and I 6. 0 New construction employees(full and/or part-time).' have hired the sub-contractors :.❑I am a sole proprietor or partner- listed on the attached sheet I 7. 0 Remodeling ship and havens employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. q, 0 Building addition [No workers'comp.insurance 5.❑We area corporation and its 10.0 Electrical repairs or additions required] officers have exercised their i.❑I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. 0.152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.12 Other comp.insurance required.] thy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, :ontraclors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site formation. /� - (� isu rance Company Name: P''(0•..S rkO io- «�.11J't wtXi CR_ \ hire' '-j olicy#or Self-ins.Lic.#: \$'.I A • Expiration Date: t—]_ t01'7 oh Site Address:)3 CGrvvykovi wee_l}d, / 2y Clv l nhI City/State/Zip: C)a Li ta7 ttach a copy of the worlrers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a da ainst the violator.Be advised at a copy of this statement may be forwarded to the Office of vestigations the DIA for insure? verage veri y on. r do hheerreby certify uner ns a penalties of p 'Lily that the information provided above is true and correct. 'gnto. Date: (-al 2iiaokb hone#: S 1.35`1-'777X Official use only.Do not write in this area,to be completed by city,or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK SPY• 06/04/2018 PERMIT # j �P1f"'0069/ —�-�—. . CITY SOUTH YARMOUTH MA DATE _ / JOBSITE ADDRESS 43 PINE GROVE ROAD OWNER'S NAME JOE QUERCIO C- OWNER ADDRESS 167 WACHUSETT STREET, BOSTON, MA 02130 TEL 508-760-4937 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL f RESIDENTIAL V( PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: 7 PLANS SUBMITTED: YES NO IN/ APPLIANCES -1 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 1 FIREPLACE FRYOLATOR l 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 1 OTHER - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [,4 NO LJ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY g OTHER TYPE INDEMNITY ❑ BOND I 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 ❑ AGENT n SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru 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 com nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE # 1229$' SIGNATURE MP [' MGF JP [-1 JGF LPGI , CORPORATION 3281C PARTNERSHIP I # LLC # COMPANY NAME EF WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com WORK ORDER #474589 / PERMIT FEE- $40.00 6Pif w_ Departrrteset of industrial Accidents . It_.-MI=ft Office of Investigations '--.. _;Fyf 600 Washington Street 14r Boston,MA 02111 .1s• www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information C Please Print Legibly Name(Business/Organization/Individual):e..c•Wtr\5�etnl Q(Vso�'Jirtel 4 klttx� Ce-,I✓tt U Address: QQPntiv., Circle— . City/State/Zip: Sookh ftMcavttib NPr Phone#: Ob-394-11?Si • Are you an employer?Check the appropriate box: Type of project(required): . I am a employer with '70 4.0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors ;.❑I am a sole proprietor or partner- listed on the attached sheet.i ?• 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. q, ❑Building addition [No workers'comp.insurance 5.0 We area corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their i.❑I era's.homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions . myself.[No workers'comp. c.152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] l.ey applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating mob. :ontraetors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site !formation. �_ durance Company Name: l n�ft Tt3 uJ Cl')/tl0Jt Pt nittt el CS_ Ct �t-A olicy#or Self-its.Lic#: `$.' { A Expiration Date: (--]" anl� 1b Site Address:D3.# tno+uil w-eo-I4 h sib.lstay CO't 0111 City/State/Zip: 6,;4 id Stark a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a da a 'nst the violator.Be advised t a copy of this statement may be forwarded to the Office of • ivestigations the DIA for insurapeEgoverage veripa on. t do hereby certify ut for.�{�e tins an penalties o p cry that the information provided above is true and correct. ignatuT (/r�t.n Date: (a1 31 I c'ZO« hone#: S(1R 35`1.777X Official use only.Do not write in this area,to be completed by city or town official • • City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other . Contact Person: Phone#: