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Home My WebLink AboutBLDP-20-005817 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ):-_ =Ere ° - �''� CITY YARMOUTH MA DATE 5/08/20 PERMIT#/3ii)/ ® `�. /7 .'» JOBSITE ADDRESS 60 RITA AVENUE OWNER'S NAME SUTLIFF,PAUL POWNER ADDRESS SOUTH YARMOUTH TEL 857.488.0283 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL EJ RESIDENTIAL EJ PRINT CLEARLY NEW:ID RENOVATION:ID REPLACEMENT:ID PLANS SUBMITTED: YES El NO - FIXTURES 7 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB '� CROSS CONNECTION DEVICEmigDEDICATED SPECIAL WASTE SYSTEM OM iiii 1111111111111111111111111111111111111 NMI dam ammm DEDICATED GAS/OIUSAND SYSTEM j DEDICATED GREASE SYSTEM aUN MK MN 11111111111.11 MI 111111111 NI DEDICATED GRAY WATER SYSTEM 111111111011111111 NM INN 0111111111111111 INN MIN I DEDICATED WATER RECYCLE SYSTEM MB fill IIIIII; DISHWASHER Mil MN 11111111 XIII 4 NM DRINKING FOUNTAIN F. . PM FOOD DISPOSER an MS AM 0111111101111111111111111111 IN.NM 1 FLOOR/AREA DRAIN 2 INTERCEPTOR(INTERIOR) ININIIIIIIIIIIIII11111111111111111111 - '1111111..- U. T 1.1 KITCHEN SINK . LAVATORY iiiHIMII I111111111111111 MI 11.1111111111111111111M111111111111111M1111111.11 ROOF DRAIN iii1.111 .N MK NM MIN 111111111MINISMIII SHOWER STALL AN 11111111111111111111111111111 _SERVICE/MOP SINK NM Om piii 0.0.0011111 .ming TOILET ` URINAL r-- r� noais � f i ..... .1, .. ili - WASHING MACHINE CONNECTION am annum am runitimilit moilmiii' WATER HEATER ALL TYPES 1 11111110111111111 SIM ON I M NMI NMI MM.IIIININIMIS IIIIIIIIIIIII. WATER PIPING _; OTHER 111111.111111111111IIIIMIIIIII .._ _. __� 'FIIIII��_ - �11111111 I. , : -_. MN 01 IIIIIIMITI k IIIIII an 1iNIna 1I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[. NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY - BOND EI 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 El 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 r e to the b t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co Ii wigyertine proYisioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,, `1 PLUMBER'S NAME I STEPHEN WINSLOW I LICENSE# 12298 SIGNATURE MP EJ JP El CORPORATION 0#1,3281C 1PARTNERSHIPO# LLC ED# COMPANY NAME' E.F.WINSLOW PLUMBING&HEATING I ADDRESS 18 REARDON CIRCLE I CITY'.SOUTH YARMOUTH 1 STATE I MA 1 ZIP I 02664 I TEL 508-394-77 78 FAX I 508-394-8256 I CELL l N/A I EMAIL INSPECTIONS@EFWINSLOW.COM L __ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .rim `°I_i-54 CITY IIARMOUTH MA DATE 05/08/20 PERMIT# ' /-M-V /7 JOBSITE ADDRESS 60 RITA AVENUE OWNER'S NAME SUTLIFF PAUL G _ __._ TEL 857 488.0238 FAX OWNER ADDRESS SOUTH YARMOUTH TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ...... RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES Li NO APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER w. iillON I NM BOOSTER _ CONVERSION BURNER ry. _ ___ " I.,.. .- COOK STOVE 1101111.111011111101111.11.1.11111.011.011111/110.11.111111111111111.11.11. DIRECT VENT HEATER WAIN IMI 1.1 11111111 DRYER .. FIREPLACE . FRYOLATOR 01111.M1111.111110M Mg owimilwrwattom g FURNACE 11110111,111.11Mill.11110111 WAIN GENERATOR GRILLE - r INFRARED HEATER 1. Wow LABORATORY COCKS MAKEUP AIR UNIT 01.1.011111.1 IOW 1 MI OVEN 111.01110011111.11-MFORIMIlliM11101.11.10111110.MOM POOL HEATER — ROOM I SPACE HEATER 1 MINIIIIIIIIIIIIIINI IIIIIIIIM MI ROOF TOP UNIT - TEST . INK MO UMW ION UNIT HEATER IIIIIIIIIIIz UNVENTED ROOM HEATER WATER HEATER 1 W/O 524934$40.00 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY E BOND Li 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 Ej AGENT El 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 complianncc a Pprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (� / ...-.. .--- PLUMBER-GASFITTER NAME 1 STEPHEN WINSLOW ---1_.1 LICENSE# 12298 * SIGNATURE MP al MGF ED JP Li JGF Li LPGI Li CORPORATION # 3281C PARTNERSHIP LI# y--1 LLC EI# COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING _I ADDRESS 8 REARDON CIRCLE ._ ____ CITY 1 SOUTH YARMOUTH STATE MA IZIP 02664 TEL 508 394-7778 FAX I 508-394-8256 CELL N/A EMAIL,INSPECTIONS@EFWINSLOW.COM _ if The Commonwealth of Massachusetts _Mow i Department oflndustrialAccidents w Office of Investigations I' Lafayette City Center.' a 2 Avenue de Lafayette, MA 02111-1750 � � Boston, ' s ' 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 90 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/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. ❑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.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ 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. #1909A Expiration Date:01/01/2021 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 cer the in and penalties of perjury that the information provided above is true and correct. Signature: I' '` â,_i:_ Date: 01/02/2020 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 2.1=1 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents Wit_ Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 1‘,—j 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 90 employees (full and/ 5. ❑ Retail or part-time).* p 6. �] Esfayblis-liment 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. ❑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]** 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. #1909A Expiration Date:01/01/2021 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 cer ' of the ins penalties of perjury that the information provided above is true and correct. �f/ 01/02/2020 Signature: Y '` ...-4 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.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia