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Home My WebLink AboutBLDP&G-20-002011 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK IV--- I MA DATE Oil ill_ L 1 PERMIT# A�1'�� =`u►I{_�� CITY YJm1u�(•�._, .. ......__...___ ...,._ - JOBSITEADDRESStIQI,_ +.-COtkcCJ.c....YWl41dA.I OWNER'S NAME t.f t le-ir GOWNER ADDRESS I .. SailraflP_.___._ ..._.._._.__ _t __.1 TE 11.1I _ - S$G 1 FAX - _ TYPE OR OCCUPANCY TYPE COMMERCIAL0 EDUCATIONAL[] RESIDENTIAL PRINT CLEARLY PLANS SUBMITTED: YESO NOD NEW:D RENOVATION:® REPLACEMENT: _' - 1 ..-..'-1 •- - _ '._.•_:, -- _ _ 13 14 APPLIANCES 7- FLOORS-► BSM 11 1 2 -I 3 4 5 I 6 7 a s 10 11 12 I�� BOILER ��-�- -�I _ -,-1 BOOSTER _ 1 .... ....,- _.f .. _._�--,. W --- 1 .. CONVERSION BURNER 1 I - - .t7-1— ® - •-- z ` COOK STOVE -.. 1 1 -•- I - .. �------.1��,,..�� DIRECT VENT HEATER WII Lrlamlll[n-- !�aV '" f DRYER - • • _. l; _. •� . _ .- ..11- FIREPLACE �� = •' ®.P- lif® FRYOLATOR �_ • - � � - ---.._. . ..I.. _I . -,. __ - �— -- rn FURNACE ; ._. _ �1 MiN_. __. IW1 _I M I: -- .. .-.. GENERATOR - - GRILLE i- --•...i.... .1 _An .. . NM _ . -- 1 Iii.JSMIIIKM INFRARED HEATER Stir - I - LABORATORY COCKS L... -._min.--... � -- - `. _FT— MAKEUP AIR UNIT I "' OVEN *it 1 _:, ._._.'I.. J - - POOL HEATER r- , _ .1 C� J _1�— ROOM I SPACE HEATER -- _- -1 _ J = _ ---__—__.-.___--- PL-:l. - . __ _ - __ __. .. - --- - R�01- I OP-UNIT- �---`� _ I ice, _,—. �... .� TEST L. ...-._--j, - ....,. �.... ' UNIT UNV NTE L- JI Ji .....Iiii DROOMHEATER L 1 - :'®I--1 .. ... r WATER HEATER 1-� __� 0 -JMLMAX II —MI MELEE !�I _ ..dl--II—•LJ OTHERgl 1111111 iliiiMAI t.. . _. :3 .1 I,._.._..---._.•,.... •--_., . . _._--- .-AL. .Ili 7317..__1f.. ....JI_..._...II ._ . II__ II_._.. : =�1 .I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES . NO D I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY IN OTHER TYPE INDEMNITY D BONDU.'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 D AGENT D 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-nd 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 compl', a with all Pertinent provision of the ;Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ ,_. t. # 1�� • ! SIGNATURE PLUMBER GASFITTER NAME STEPHEN A.WINSLOW. _ _ _ LICENSE# 12298 MP 0 MGF D JP D JGF 0 LPG!D CORPORATION 0#`3281 C_, _ i PARTNERSHIP D#� 1 LLC D# a' COMPANY NAME:I EFWINSLOW PLUMBING&HEATING ,- ADDRESS I 8 REARDON CIRCLE ,�-- - . , _,... ._._. . MCITY I SOUTH,YARMOUTH, . ... .- �..,_..___.w_.._,____.I STATE _MA 'ZIPI 02664_ ,_.�TEL L 508394-7778. , _ : ,_._ __,_.•i__ v., FAX 508-394-8256 CELLI NIA ...'EMAIL)accounts ayable@efwinslow.com • • Pd .cbc 2-09 3 r . o�0 cO I f ?3 The Commonwealth of Massachusetts • i. ., � 1, Department of Industrial Accidents =elfi=10-n_= 1 Congress Street,Suite 100 _,�� —_ r Boston,MA 0211.4-2017 �;� '< www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. \ Applicant Information TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Legibly ''' Name(Business/Organization/Individual):E.F. WINSLOW PLUMBING & HEATING CO., INC Is� Address:8 REARDON CIRCLE � City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: �+ Type of project(required): 1.0 I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction _ 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling - any capacity.[No workers'comp.insurance required \,+ 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10❑Building addition q 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions k. proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lic.#:1909A Expiration Date:01/01/2020 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and e pal s nd pen lties ofperjury that the information provided above is true and correct 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(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 PLUMBING WORK • _ '2 // CITY YARMOUTH MA DATE 10/4/19 PERMIT# BLDP-20-0 f[= JOBSITE ADDRESS 49 CAPT CROCKER RD OWNER'S NAME RODGERS MARIAN L P OWNER ADDRESS 49 CAPT CROCKER RD SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL D RESIDENTIAL D PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES FLOORS—s BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE 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 1 WATER PIPING 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 TYPE 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'S NAME Stephen Winslow LICENSE 19298 SIGNATURE MP ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME EF Winslow Plumbing&Heating ADDRESS 8 Reardon Circle 49 CITY S Yarmouth STATE MA ZIP 02664 TEL FAX CELL EMAIL accountspayable@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT El El FEES$ PERMIT# PLAN REVIEW NOTES