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Home My WebLink AboutBLDP-23-8510 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK •�`°lf_ CITY Yarmouth i MA DATE 5/3/23 PERMIT# I oO— 2-1— ri ° a. JOBSITE ADDRESS 50 Holly Lane I OWNER'S NAME Keith Shaw 1 POWNER ADDRESS same TEL 508-398-6768 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL Lj EDUCATIONAL -I RESIDENTIAL El PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES fl NOL FIXTURES Z FLOOR—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I ' " I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM 'nr.MnnnMnnillWIISSPi DEDICATED GREASE SYSTEM , DEDICATEDi C.................. FLOORiimp DISHWASHER im" _. _, i1,11,mi gra aim E.am alliiiiii rim Ma a. DRINKING FOUNTAIN FOOD DISPOSER on... ,....m.....,. AREA DRAIN INTERCEPTOR O. .KITCHEN SINK LAVATORY !Iall, 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET { 1 URINAL -- WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING Liiiiiien========= 11111 OTHER 'Egli { INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES- NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY I] BOND I „J 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 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 li with II ertine pro'isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r '` ,....o ___ PLUMBER'S NAME STEPHEN WINSLOW i LICENSE# 12298 i SIGNATURE MPU JP[1] CORPORATION LI# 3281C PARTNERSHIP®# LLCI# COMPANY NAME E.F.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 INSPECTIONS@EFWINSLOW.COM MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,w CITY ;Yarmouth MA DATE J PERMIT#BL b P-- 2-1 - S fo JOBSITE ADDRESS 50 Hold Lane .1 OWNER'S NAME Keith Shaw OWNER ADDRESS Esame TEL508-398-6768 FAX TYPEP OR OCCUPANCY TYPE COMMERCIAL r .2 EDUCATIONAL RESIDENTIAL °` �� NT CLEARLY NEW ,j RENOVATION:' � REPLACEMENT: m PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER = - CONVERSION BURNER _ , COOK STOVE _ .._... . DIRECT VENT HEATER p DRYER , t FIREPLACE FRYOLATOR ` FURNACE GENERATOR �.,. . � �: � �, ...,�;:. ,.,... ...W....: .,r GRILLE INFRARED HEATER ra LABORATORY COCKS MAKEUP AIR UNIT l °, E OVEN POOL HEATER ROOM/SPACE HEATER �, ROOF TOP UNIT TEST e UNIT HEATER UNVENTED ROOM HEATER " yr. I WATER HEATER �.._ - OTHER x INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [° NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v 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 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 aP�ertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 71 ' // 7/F/•' ,...o. .— PLUMBER-GASFITTER NAME'STEPHEN WINSLOW _ _--1,,j LICENSE#L 12298 SIGNATURE MP S'; MGF:„7:; JP; _ JGF1 LPGI' CORPORATION '# 3281C PARTNERSHIP' #j ' LLC # COMPANY NAME:'E.F.WINSLOW PLUMBING&HEATING _ ADDRESS.8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ,ZIP 02664 TEL�508-394-7778 FAX'508-394-8256 1 CELLI N/A u _�� _„ EMAILIINSPECTIONS@EFWINSLOW.COM tN, The Commonwealth of Massachusetts MO. Department Department of Industrial Accidents h /- Office of Investigations 1-1j . a Lafayette City Center _ ��, —� _` 2 Avenue de Lafayette, Boston,MA 02111-1750 At 'M �' 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 120 employees (full and/ 5. El Retail or part-time).* 6. El Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. El 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.El We are a corporation and its officers have exercised 9. El Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.El 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:23 Commonwealth Avenue City/State/Zip: Chestnut Hill, MA 02467 Policy#or Self-ins. Lic. #2019A Expiration Date:01/01/2024 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('ceer of the ins and penalties of perjury that the information provided above is true and correct. Signature: `� �,'� -«-m�,,�.- g 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.❑Building Department 3.0 City/Town Clerk 4.['Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia