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HomeMy WebLinkAboutBLDP&G-21-006150 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I CITY YARMOUTH MA DATE 4/23/21 PERMIT# BLDP-21-006150 6 ,, JOBSITE ADDRESS 18 TELEVISION LN OWNER'S NAME KURTH REYNOLD P OWNER ADDRESS KURTH MAUREEN J 18 STUYVESANT OVAL APT MA NEW YORK,NY 10009-2256 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 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ BOND El 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 112298 SIGNATURE MP ❑ JP El 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 .ti im CITY " rn 9 MA DATE1,..qi„Nli,L,,,,j PERMIT # d ( 006 JOBSITE ADDRESS l TE Ie✓fs; -,L n _.1.n!i. a.1_.nd - _,, OWNER'S NAME ___ _ )d__._. ___ i PWNER ADDRESS It ��'v Uf �Y1:1-- Oita d i tVt . TEL - _, 5.f $,,, F L ,_-.T-�. , ._,r,-j N( 100oot TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 1 — PRINT CLEARLY NEW: ... ! RENOVATION: U REPLACEMENT: lair PLANS SUBMITTED: YES L.._,; NO .___ FIXTURES Z FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB PPR,..„---•1 -J:71L--4:_ure,f .--_-_-_4=j ,-_---- -;..--- -- --„-__- . .=__..7-- .-_,_ IIII”IlNi . ___3 CROSS CONNECTION DEVICE i DEDICATED SPECIAL WASTE SYSTEM L- __ . . 1 - - a_._ ._ `' �.j� . ._._ . . .�;_.. -. . 1 . -- ---- --- . ,,,.,,_ I DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM --- _ i ___y... -_ . . ,..... _-._. ___ .._' _— _____.... _;......._` I -- , -.: - - -- `'' DEDICATED GRAY WATER SYSTEM t--. _: _•_•- ce.- �•c;U�Sfi• -1-:�...._. .t.-.T.—�_.:a- _—__..=ice i��-,-='-.-.� ___..„1„'Il`-.__ _.-�,,�ti�z�:l DEDICATED WATER RECYCLE SYSTEM L . �._ _ iLiL-- Ji .� =._'FL___ _ .�__�_I .....„.1___ _IL._.=FLT�.. 1,�:.,- =_, 1 , ..,--i i* �- --- DISHWASHER .a._.i—.._-..s=�.ITT.._�� .... ._..._• fe��__--�—_-_""----.+.i,�i' f�.•�.'�.iSi� L-- :'i{i 11---_,..___: ri_'r_�+ w DRINKING FOUNTAIN FOOD DISPOSER II' (p t II}L _ r L.,,J1_,,JL_.„__:, „i: _.._. ' 1....i, r11 T_. FLOOR/AREA DRAIN I _ INTERCEPTOR (INTERIOR) ..�,.-__. jL . . _if . z...� L-- �_ h - - -____ V_ ���,�. '_-- 1, - ' KITCHEN SINK M. _ LAVATORY t( ( !, ,,____7L.16._,: ROOF DRAINW _ -- _ i SHOWER STALL Milli - T,L . --_ �_ _ _ ;' SERVICE / MOP SINK . TOILET � � .. _.__.._ ___ _. __._._•-_ II _ _ URINALL. L WASHING MACHINE CONNECTION : Ij. __ ___4t__ __' _ _ _ `_.I y _,__ ,r - ' WATER HEATER ALL TYPES 1 WATER PIPING __ I _ _t _-__--'J .. . IL----'-- ---- --- -. ' ___ ._,..._-__. - —_1_,____,.: ----., I OTHER � _� _ � W:��t.,,y, dF-0�'_ -+A+c:,T.<'-C_i.. _c 3,_ Ili z.. _s 1 — _..- _-___.._.-. _ __._...__ _ - - __ i ..,,.—..._. ...._-' �M 'yaws.....OTHER .. .'G' L ew'� 1:- a.�na..':. T.'"".e(= L .�,c# _ _ __-j__ _.. __ _ _ -__- .. ,-- �i� 1 r r---`— --._._ j —._. �.—��---_ w-.,�- �_�-,. .�._.�r'I�..:.c_:,�rl -c--_--� _--- '------i1 --' , ...--�I ..1 -- ___._. ...- ._ _ -_...--- - _. {j ,i _ tr _ I,.i J I I. I �( _____-_ -_-.-__-.._ ._.__..___ti._.._._ -- _, INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO LA IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Lii OTHER TYPE OF INDEMNITY 0 BOND L, 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. t CHECK ONE ONLY: OWNER 0 AGENT I.......y 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 If io ertine proyis of the ' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r � `P �' ]LICENSE # 12298 SIGNATURE PLUMBER'SNAMESTEPHENWINSLOW ,� �� W UN MPO JP L CORPORATION FPI 3281C PARTNERSHIPEP LLC TI# ,--1 COMPANY NAMELE.F. WINSLOW PLUMBING & HEATING ADDRESS F8-REARDON CIRCLE Tr- CITY I SOUTH YARMOUTH STATE IMAl I ZIP {02664 TEL 508-394-7778 _______ FAX [ 08-394-82561 CELL {N/A -1 EMAIL INSPECTIONS@EFWINSLOW.COM • _-����- _ T ______ The Commonwealth of Massachusetts _. Department of Industrial Accidents l Office of Investigations "" '� a Lafayette City Center Z Avenue de Lafayette Boston,MA 02111-1750 :r 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): 1.0 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.] 12.0 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.#1964A Expiration Date:01/01/2022 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 • i��the plzAin's�d penalties of perjury that the information provided above is true and correct. Signature: ``jj^�� 1' Date: 01/02/2021 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): 1.111Board 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Vitirl CITY YARMOUTH MA DATE April 23,2021 PERMIT# BLDP-21-006150 JOBSITE ADDRESS 18 TELEVISION LN OWNER'S NAME KURTH REYNOLD G OWNER ADDRESS KURTH MAUREEN J 18 STUYVESANT OVAL APT MA NEW YORK NY 10009-2256 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 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© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsAefwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE:$ PERMIT# PLAN REVIEW NOTES _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4 7 . .r _� I_ CITY {. tiiti�i4i MA DATE , �c1Z IJPERMIT# a�. C� 1-c- v� L1 C1 FI f�G%Rk3C9FltiK _ I i.:�....iii,: JOB SITE ADDRESS j la rs ir.d u,,,, 4 qg OWNER'S NAME r. l 1==== 1:— �� G OWNER ADDRESS Li 4 b e an4- )vuA - 1�A de ' rTE4 0JIFAXE7L ) - - TYPE OR OCCUPANCY TYPE COMMERCIALLY,' EDUCATIONAL i PRINT _ RESIDENTIAL P--- CLEARLY NEW:0 RENOVATION: 0 REPLACEMENT: [.-T' PLANS SUBMITTED: YES NOD APPLIANCES -]. FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1:,:-=311.�._—,- . .1F 1~ 31.�..-_. 1.r.,-...-J I�T 1_ rr Ty T if-_ i! _-11 G.____r ET __ BOOSTER ` -----�� - .l�=�-----r� -�, - �I�---� -- ` - ; �____..� _. � ___.;, .__._-.-_r , ,a� _ r_l L 1 . .11._ .ii.1_..-- 1. . -11. . T i.. . . 1� . .31T--- r -- -I CONVERSION BURNER L.. �...f.i.17,-.. ---: .......__ �--11�__ _ _I _ ... __y' . . . Y, K STOVE :--- - -- ._.. _--__ ,- ---__ =- -__-.-�� __. - COO - ' Lii_____T____:(1:11..i !.�_,...' L._... -1__..- I.-.___ �, _._ _I I__,_�. T___.L I.�__ 1_ -_. DIRECT VENT HEATER >�._ _�1 l. --•-,..11_T....,_._!�(. __.. I: ----: , 71 -- -- -' � M, � _. ......�.: 3-_.._ I .�.. _ �.r DRYER 1. -L _. - -- �T,,�T-. c I` _- I_—!I�;i f= L� �:� I�_� I�� ,t ___ _ ' FIREPLACE I �ETD I� {`1 _ ( I •. �.1,l^_ , _ �[ ' ��� - y' � 1 .rt'F,_j..Y.�.�J. :_�,..f-�..... ..-. :.r�_ .. .-.. ♦ ♦ ..i, f T r� , FRYOLATOR -- - _ _ . .MITT . . �._,---.. .-,:L-�.--,..�_���,. . �! -�. ! 1 -- ' • FURNACE -�--�•� i. If . __. � _ �._..�.�_. �.. fi: j. __ ♦ _.-._. r.�.. . i .r . CT I--T 17. I.-7,i l;. -� ..-�I_._--__I'1..._._ c _- i _I; �?� GENERATOR -IIL:TM 1 1. _ _11- :_ l_.T..__:I._. 7 [7:= {i,------ I- --- '�L- - --;1--- ! C lL7i .I ___ GRILLE 1 _ _,�1- _-.- I_—.'I-_-.�.��1- ---`-I-- -I ----�1- -_{' -T ! ------- �---7�.f I— L_—J'I,. INFRARED HEATER L._._,-,.:.- :I-. .---` --- -.c L T- --1:177. TE---I 1.._.._T!: ----_ l E•__ . _._I]1_.--till 1 I___�^l r �: LABORATORY COCKS I I — �� -- � r °� ' I�_ •(.. _, I✓z Ii Iw_ __I`I - _i I JI-.__ I",..__._--I' ----- l._-- . i-•.___ i___-_ L,____!L_._? ______1 MAKEUP AIR UNIT � ` � I•j__._.ice ����`' ------OVEN —� . _.:-.�►.1:T..:....:__•�:1.._. .I__._.,._._ %I^__j .—:_. i T 1 ►i i_ _ 1, i POOL HEATER - - --- -- ----=, - — -- -'�._�-_--`I_.�---_. I.--__:l-�_-- '--- I T-3 I..._.�,,; I.:._ __ �[— -- 'I�.--_.-- q- .. t I_.,.__._!� fI L____ 7 1..•___..: I:_ 73:F--- 11---I:1--_..� I. ROOM /SPACE HEATER Lx...,. 11.--- --I I' _--- '' --:'-ll i' --. ._ . ,. ROOF TOP UNIT - i - --- -- - •-- -� - - -- r1.=_�� .--..... _ �r _ ._,. r Cam:[---1_11-----_ �=(^--�-� I--_�I:I� I _ _ 1_- 1----- [ _J i 1..� !31 t s -__ , r TEST • [�-„::�_..i .,., ._.__,► J�—=...I I. .~p r�.--._r....-I I..�,._._. t..... _-._-;a __ r - --^J 1^-___I' -:j _. i UNIT HEATER "� ;� ,- --� � -��-_..--, ----�,. . _ � : , �..--- 1� _.�I I�.. . . _ � --3. — !`r;.i 1, ! I - 1 I ! 1--- __1 ______. I ..._--- I :1__J - —� _.-= UNVENTED ROOM HEATER -17:3 _ JET:FL ___If 731_ �Y?Y_L'i3.S.:�o'.CYY'YJ.:.C♦i`RKItiI. _-_t._._r_..... _ _..s.LS.aWrilalYl`tAY iia+.G 1 - ' f z� -IL- _ �. _�_ J` -WATER HEATER i I , l i I - .OTHER_ __� Y _ _ __ __- ! i___ _i r , i I jI-____° 7 . _7 :3 u _ -_y _ .L_-- - - ( .�Ial t _ M7 ! " 1 I 1 iiF___ -i I.._.- 1. ...-._-_•I'�-•.--• ,:1 •---..._ ._..._I ___--" _�•I•---•__..-..1•1.....t._-..l Y -3 I:_..�-..�I_�-....-J __-I 1-_—_= �: 1, ,, ){�^'�`` +I ..v.6.r../lia'd:4i14'8f4:1:Nliv "•[s'lt✓111:!!W➢LOii6G7L•• -^-5`•.�T-KSrcar:a.ae__t3!.1C414ti i' 1 - - •-t - .... - I,I• + -, . I'. . __Id_/_ :1:-r-r ..:-.I� —- INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES IT NO 0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [Ti OTHER TYPE INDEMNITY �,,,_:_, BOND 7 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 thatmy signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT L_!1 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 compliant a P rtine provision of the �' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMELIHEN WINSLOW —� LICENSE 412298 �1 SIGNATURE MP [JJ MGF [ JP r JGF[.�.: LPGI fl CORPORATION FP [3281 C 1 PARTNERSHIP Ottr . .. ..�_- jl LLC[I# T� -'11 :.� �;l COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE ��_ !� T. TT� __._ CITY FSOUTH YARMOUTH _ 1 STATE r MA J ZIP' 02664 5 M ��m � __ � . =- ._._.-...�-w._._�.. - _.._.__.._ - .�._..._.....�....�_.._�TEL�508=394w7778 C-' FAX 508-394-8256 I CELL NIA 1EMAIL1JNSPEC1ONS@EFWNSLOWCOM The Commonwealth of Massachusetts Department of IndustrialAccidents T Office of Investigations 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 2.0 Iam 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. 8. Non-profit [No workers' comp.insurance required] 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]** 11.0 Health Care 4.0 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.#1964A Expiration Date:01/01/2022 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 ' lef the jjhi`ns and penalties of perjury that the information provided above is true and correct. Signature: 7' Date: 01/02/2021 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 3.0 City/Town Clerk 4.0Licensing Board 5. J Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia