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Home My WebLink AboutBLDP&G-20-000781 $J, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK YARMOUTH 08/07/2019 p 6+-rzrJ CITY/TOWN MA DATE PERMIT# /" 787 JOBSITEADDRESS 300 BUCK ISLAND ROAD % D OWNER'S NAME BLOOM,IRMA OWNER ADDRESS WEST YARMOUTH TEL 508.771.3210 FAX 610.608.3342 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED:YES❑ NO j' FIXTURES- 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/01L/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 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 ALL TYPES 1 WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Cal' NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M' 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 ❑ 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 coin I nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. te J, �ntc— PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MP 12 JP❑ CORPORATION Eif# 3281C PARTNERSHIP❑# Lc❑# 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/Bfefwinslow.com WORK ORDER 506244$40.00 The CommOnWealth.of MassackusettS Department of Indusril.A.ecidents $, 1 Congress-Street, Suite 100 Boston, MA 02114-2017 www.moss.govidia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERIIIYf1NG AUTHORITY: Applicant Information -. Please Print Leeibly Name (BusinegeOrgoization/Individual): E.F. WINSLOW PLUMBING & HEATING :CO., INC Address:! REARDON'CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone #:5°8-394-1778 Are you an employer? Check the appropriate box: -8 8 . Type of project (required): am a employer with employees(full and/or part-tune).* 7. [] New construction ,1:1 I am a sole proprietor or partnership and have no employee.s working for me in 8. Remodeling any capacity. [No workers' comp. insurance-required.] -9 El Demolition 3,Lj l am a homeowner doing II work myself. LiNio wcrkers'comp._insurance required.)1 10 El Building addition 4.0 tam a homeowner and will be hiring contractors to conduct all work On My property, I,wilt ensure that all contractors either have workers' compensation insurance or are sole ii EI Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additiona 5.01 am a general Contractor and Lhavebired the sub;oontractOrs-listed on the attack:Oils:4 . These sub-contractors have employees'and have woricers'comp.inauratiez.t 13 0 Roof repairs 6.0We area CorpOratipa and its.officers.have exercised their fight of c*cmption per-MGL 14 Ei Otherc. 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 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 haveemployees, 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. Insuititice,Company Name:ARROW MUTUAL INSURANCE COMPANY Policy# or Self-ins. Lie. #:1909A Expiration Date:°1/01/2020 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 to2$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 $20.00 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, 1 do hereby eertifi und pai s putpei, fries of pedury 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:Blinding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone#: Contact person: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE DRfm/901g PERMIT#A0✓I' 2-oid 77/ JOBSITE ADDRESS 300 BUCK ISLAND ROAD,UNIT 3D OWNER'S NAME BLOOM,IRMA G OWNER ADDRESS WEST YARMOUTH TEL 508-771-3210 FAX TYPE OR 610-608-3342 PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL_[ CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[a/ 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 aE 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[v7 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 corn -nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. S PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 1229,67 SIGNATURE MP[v7 MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION g# 3281 C 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 accountspayablel efwinslow.com WORK ORDER 506244$40.00 �� ti The.Comrnonwealth of Massachusetts Department of Industrial ACCidents gq'�.Iw. t � ms= 1 Congress:Stree4 Sul a 100 r'.t `1_ Boston, MA 02114-2017 • 141 t44 www. nass.gov/dia Workers'. Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO ESE FILED WITH mg-PERMITTIN.G AUTHORITY;: :Applicant Information Please Print Legibly Name (BusinesslOrganization/Individual):E.F. WINSLOW PLUMBING & HEATING .CO., INC Address:8 REARDON CIRCLE- City/State/Zip:SOUTH YARMOUTH; MA 02614 Phone #:508'394-7778 Are you-an:employer? Check the appro.priate,box: Type.of project (required): l G✓t 7 ant a employee'with 88 employees(full and/or part-time). 7. 0 New construction 2�-I am-a sole proprietor or partnership and have no employees working for me in. $. Ei Remodeling any capacity [No:workers'comp. insurance required:] .Q,I am a homeowner doing-all work thyself. [No workers',comp. )',.insurance required. :.9. [] Demolition 10 [ Building addition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that ail contractors either have workers' compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 50 I am a general contractor and I have=hired the sub=contractorx listed on the attached sheet These sub-contractors have employees and have workers' comp, insurance: 13. Roof repairs = 14.ID Other 6.0 We:are:a eorporation-and its.officcrs have exercised their right.of exemption per MGL.c. 152,§1(4),and we have noennployees. [No workers' comp. insurance required.] "Any<applicant that checks-box#.l must also fill out-the section:below showing their workers' policy information. t Homeowners who submit this affidavit indicating they are doing all:work and then hire outside contractors must submit a 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 insurancefor m, employees. Below;is the policyand job site P � �P y .� information. Insurance Company Name :ARROW MUTUAL INSURANCE COMPANY Policy # or Self-ins: Lie. #: 1-909A Expiration.Date:.01101/2020 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 $1,5.00.00 and/or one-year imprisonment,:as well as civil penalties in the form of'a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. A copy of this'statement may be forwardedto the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify Un i a dater pal s t cl pen hies of perjury that the information provided above is true and correct Signature: ...a, 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#: