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HomeMy WebLinkAboutBLDP&G-21-002164 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ^_= CITY YARMOUTH MA DATE 10/21/20 PERMIT# BLDP-21-002164 JOBSITE ADDRESS 19 BARNACLE RD OWNER'S NAME ISHAM ISABELLE K TRS P OWNER ADDRESS ISHAM HAROLD K JR TRS 19 BARNACLE RD YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES FLOORS 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 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 D 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 12298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES ..- Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,w �` CITY YARMOUTH l MA DATE 110/14/20 � PERMIT # &DP /' irei JOBSITE ADDRESS 19 BARNACLE ROAD OWNER'S NAME[SHAM, HANK POWNER ADDRESS TEL 508.362.6962 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL _j RESIDENTIAL H. „I PRINT CLEARLY NEW: i i RENOVATION: ' ' REPLACEMENT: [.'__I PLANS SUBMITTED: YES LI NOH FIXTURES - FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I, I -11 CROSS CONNECTION DEVICE ,,,,„, Mill :nom rill= J F _ ____0 :_,_.„,: DEDICATED SPECIAL WASTE SYSTEM ___. DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM ,I E { I DEDICATED GRAY WATER SYSTEM MB NU MI �1 _ _I DEDICATED WATER RECYCLE SYSTEM —r__, I'�._.�I. _._I IIIII J MI a MillimMi- IDISHWASHER imi Toni..dmuiuh....iommimigulm .DRINKING FOUNTAIN FOOD DISPOSER I I'. _ : IC FLOOR / AREA DRAIN 111.111111 - i INTERCEPTORIIIIIIIIIIII (INTERIOR) KITCHEN SINK MINOIMj ;, iiiiii 111.111111111M LAVATORY . , Fmk immmiiiii Molion --1 it MI i111111111111m.0. - SHOWERSERVICE / MOP SINK . ; , 11! 11,11 -- filialligialial" ' . ' ilMaiiiMBNM WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I ,1 # • MR i WATER PIPING ,. OTHER -ir 711 ''---- - -- r-- - - - - ' MO 538503 $40.00 -_.-...c.. . . ..r.., .. ......,.. ,,. .:.....,Y..,1 y... _.....}} is lir �. 1 . w 1 r.. _.. IIII I ' INSURANCE COVERAGE: _ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Li NO J IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ? i I OTHER TYPE OF INDEMNITY { BOND 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 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 with II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW ILICENSE # 12298 SIGNATURE MP; v JP Lj CORPORATION L d#13281C JPARTNERSHIP[ I# LLC_ # COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 18 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 1 TEL1 508-394-7778 FAX 508-394-8256 CELL N/A I EMAIL I INSPECTIONS@EFWINSLOW.COM ' f turU __ The Commonwealth of Massachusetts Department of Industrial Accidents ..- Pli Office of Investigations Lafayette City Center ilg 2 Avenue de Lafayette, Boston, MA 02111-1750 ' '';.- 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]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care 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: 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 ins and penalties of perjury that the information provided above is true and correct. / 01/02/2020 Signature: Y '� .... --- 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,❑Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.0Licensing Board 5.D Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia \- The Commonwealth of Massachusetts Department of Industrial Accidents -- Office of Investigations W Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care 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: 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 ins and penalties of perjury that the information provided above is true and correct. Signature: Y ...••../ 01/02/2020 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 30 City/Town Clerk 4.El Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia I- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t.141411—eCITY YARMOUTH MA DATE 10/14/20 PERMIT# bc_o -)-/- JOBSITE ADDRESS 19 BARNACLE ROAD OWNER'S NAME ISHAM,HANK POWNER ADDRESS TEL 508.362.6962 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL Li RESIDENTIAL El PRINT CLEARLY NEW:I I RENOVATION: REPLACEMENT:Li PLANS SUBMITTED: YES J NO FIXTURES Z FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I� — J 1 )I 1 If— t� CROSS CONNECTION DEVICE I DEDICATED SPECIAL WASTE SYSTEM I' DEDICATED GAS/OILJSAND SYSTEM ii I DEDICATED GREASE SYSTEM 'i ri.. DEDICATED GRAY WATER SYSTEM L i 1' DEDICATED WATER RECYCLE SYSTEM [� l —�1 __-- I li DISHWASHER DRINKING FOUNTAIN 11 `— FOOD DISPOSER R;---- U �" ; If FLOOR/AREA DRAIN i INTERCEPTOR INTERIOR 1 KITCHEN SINK 1 ,_ _ ;� i_ r LAVATORY I �� Ii 1i I ROOF DRAIN -I _ � ` � 1 I SHOWER STALL I r II l� 1 1 SERVICE/MOP SINK (' I TOILET , 1 URINAL Li WASHING MACHINE CONNECTION 1-1if—' (- [ J WATER HEATER ALL TYPES 1 �_ ��� t: WATER PIPING OTHER 1i J , I L E, 'MO 538503$40.00 _ 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES EJ NO 1J IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY !a BOND �_.1 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 Lj AGENT Li 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 proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. —. �� PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MPH JP❑ CORPORATION0# 3281C PARTNERSHIP®# LLCI I#) COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE, r CITY I SOUTH YARMOUTH I STATE I MA I ZIP 02664 TEL 508-394-7778 fit,I FAX 1508-394-8256 I CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM I teg 40 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK mot= CITY YARMOUTH MA DATE October 21,2020 PERMIT# BLDP-21-002164 JOBSITE ADDRESS 19 BARNACLE RD OWNER'S NAME ISHAM ISABELLE K TRS G OWNER ADDRESS (SHAM HAROLD K JR TRS 19 BARNACLE RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 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 FIREPLACE FRYOLATOR • 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 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 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-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP 0 MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑#I I PARTNERSHIP ❑# LLC ❑#1 COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 18 REARDON CIR, CITY IS YARMOUTH I STATE IMA I ZIP 1026641207 I TEL I FAX 1 I CELL 1 1 EMAIL Iinspections(c�efwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El El FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .1 CITY YARMOUTH MA DATE 7 10/14 2-0 PERMIT # 13CD6 - At- O2A ar T JOBSITE ADDRESS 19 BARNACLE ROAD, YARMOUTHPORT OWNER'S NAME (SHAM, HANK , _ GOWNER ADDRESS __1 TEO 508.362.6962 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO`_.✓.. APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER l BOOSTER I _ CONVERSION BURNER $ COOK STOVE _ DIRECT VENT HEATER DRYER FIREPLACE - ....w�..._____r_........�ne. .,__ FRYOLATOR . 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 W10 538503 $40.00 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ' / NO ,,,J I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER E'fE INDEMNITY oroon 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 El 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 I a P�ertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �t/ Y - ,...../........- _____ - PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP / MGF JP j JGF Pi LPGI CORPORATION # f 3281C PARTNERSHIP . # -. LLC L # F. COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 ; ITEL 508-394-7778 I FAX 508-394-8256 CELL N/A 'EMAIL INSPECTIONS@EFWINSLOW.COM r- ,-------- -- g OcT 20 . 13 y ---- The Commonwealth of Massachusetts Department oflndustrialAccidents t Office of Investigations • =� 1= Lafayette City Center E =-�4— 2Avenue de Lafayette,Boston,MA 02111-1750 -- * 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.NJI am a employer with 90 employees 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. El 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]** 11.0 Health Care 4.❑ 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: 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 pl ins penalties of perjury that the information provided above is true and correct Signature:`' Yf/ 1,{/ 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): L❑Board of Health 2.0 Building Department 3.1=1 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia 4 The Commonwealth of Massachusetts Department of Industrial Accidents "� 1-4 Office of Investigations > Lafayette City Center _! 2 Avenue de Lafayette, Boston, MA 02111-1750 '`'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): 1.0 I am a employer with 90 ____employees (full and/ 5. 0 Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I art 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. El Non-profit 3.0 We are a corporation and its officers have exercised 9. 0 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.] 12.0 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: 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 ' e the ins/and penalties of perjury that the information provided above is true and correct. Signature: Y "` '`'� 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 2.0 Building Department 30 City/Town Clerk 4.0 Licensing Board 5.❑Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK IFS•=- .�t_ _;; 96 /*- 6vy 11VNt e CITY YARMOUTH MA DATE 10/14/20 PERMIT# ,8 JOBSITE ADDRESS 19 BARNACLE ROAD,YARMOUTHPORT OWNER'S NAME (SHAM, HANK OWNER ADDRESS TEL 508.362.6962 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 4] EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO � 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 FIREPLACE FRYOLATOR 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 OTHER W\O 538503$40.00 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 lV J1unvnvL POLICY OTHER TYPE INDEMNITY onto uvl.✓ 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 aJYPPrtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. !/ PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP MGF JP JGF LPG' CORPORATION #L 3281C I PARTNERSHIP # LLC # COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON'CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX L 508-394-8256 CELL N/A ;EMAIL INSPECTIONS@EFWINSLOW.COM OCT 2_0 624' U