The URL can be used to link to this page

Home My WebLink AboutBldp-18-006608 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -_' ' � CITYITOWN YARMOUTH MA DATE 05/18/2018 PERMIT#i'�Y�$ �0 j_ gt JOBSITE ADDRESS 33 PHYLLIS DRIVE OWNER'S NAME AREVALO, ERNESTO P OWNER ADDRESS YARMOUTHPORT TEL 617-529-2879 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Q PLANS SUBMITTED: YES❑ NO El FIXTURES 1 FLOOR—, 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER PIPE ICE MAKER 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES I NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Er 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. CHECK ONE ONLY: OWNER 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application ar rue 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 .�pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 IGNATURE —. MP 12 JP❑ CORPORATION Q'# 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 accountspayablec efwinslow.com WORK ORDER 473203$70.00leik 2u �� _ Department op'Industrial Accuienars t` i Office of Investigations li1l1`_ 600 Washington Street `'=`1tii_= `r Boston,11L4 02111 }�s..,0 www.mass.gov/dia • Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information J Please Print Legibly Name(Business/Organization/Individual): e.,C• A/w S Q� O(v�`^V `►t•a'� Ce., frit Address: 2 a( ctt,i l C: 'Q-- . • City/State/Zip: Soo kvh k^ MP+' . Phone#: 50f-3g4-1T7 • Are you an employer?Check the appropriate box: Type of project(required): I am a employer with '70 4. 0 I am a general contractor and I 6 El New construction employees(full and/or part-time).* have hired the sub-contractors 7 Remodeling ;.❑ I am a sole proprietor or partner- listed on the attached sheet.t ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their ;,0 I am ahomeowner doing all work rightexemption per ofMGL 11.0 Plumbing repairs or additions p myself.[No workers' comp. c.152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] lily applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. n (� tsurance Company Name: 4'�Y_YO•3 �J o r 6(' ` ov rid olicy#or Self-ins.Lie.#: j$a 1 A. Expiration Date: k'-1 - aon )b Site Address:�3 Cr.ivvekon vj2 Q'( Att-.41 0 I'M\ City/State/Zip: C),)14 t*7 .ttach 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 ainst the violator. Be advised ,?t a copy of this statement may be forwarded to the Office of • tvestigations the DIA for insurae- overage veri' a,on. i do hereby certify insdser a sins an penalties o pe jury that the information provided above is true and correct. t Date: (0.\31 `1 ao19 'lane / f4. hone#: *Sif-31M- '7 77D 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 y ' CITY YARMOUTH MA DATE OS/1 R/7D1 R PERMIT# A-M7/1-4°Oa JOBSITE ADDRESS 33 PHYLLIS DRIVE OWNER'S NAME AREVALO, ERNESTO GOWNER ADDRESS YARMOUTHPORT TEL 617-529-2879 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:El RENOVATION:❑ REPLACEMENT:[r PLANS SUBMITTED: YES❑ NO g APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE t DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [V7 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E OTHER TYPE 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. 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 tru 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' ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. —Atae,14-, (•i n ic -Att✓ PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE# 12298 SIGNATURE MP 2. MGF El JP El JGF❑ LPGI❑ CORPORATION g# 3281C PARTNERSHIP❑# LLC El# 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 473203$50.00 c // U" �� Department of industrial Acciaents �} l'E' Office of Investigations t.=::r= -• 600 Washington Street =1,E1= Boston,MA 02111 • 4Y 444 „�Ihill ww».mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information J I Please Print Legibly Name(Business/Organization/Individual): e.1•W Ir,5 t 0vJ Ct(V. �i Q V4+� 0- ci. 1 et(. 0 Address: 5' Pea curl C I e- City/State/Zip: So,s kv\ v t` Pr Phone#: h-3ct4,1'7? Are you an employer?Cheek the appropriate box: Type of project(required): ., -I am a employer with -70 4. ❑ I am a general contractor and I 6. El New construction .employees(full and/or part-time).* have hired the sub-contractors .0 I am a sole proprietor or partner- listed on the attached sheet.t 7 0 Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We area corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their i.0 I am'ahomeowner 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.] k.ny 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. :ontractors 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. _ {� tsurance Company Name: •.,.s Cv r"oA wc&1(Z. \ e ^' `/1`1 olioy#or Self-ins.Lic.#: VB a[ A • Expiration Date: (-1 — ant-) sb Site Address:a 3 G.Artmetri\.r-e a-( h > l C ' 1'V;\1 City/State/Zip: O,.)4 67 7 .ttach 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 ainst the violator. Be advised at a copy of this statement may be forwarded to the Office of tvestigations the DIA for insurnie overage ver51693 1.on. i do hereby certify under a atms an penalties ojtpe ljufy that the information provided above is true and correct ignatC. ur : /4 A.A. Date: 1 DI 31 t !AMC hone#: .5t11.3S1`ii• 7 77X 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#: