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HomeMy WebLinkAboutBLDP&G-20-006056 K8ASSACHUGETTSUN|RORM APPLICATION FOR A PERMIT T0 PERFORM PLUMBING WORK EIJICITY -------- _ | �A OATE 1PE��|T# AZ �lM '���^�� J08SITE ADDRESS _38_CAPTAIN SMALL ROAD OWNER'S NAME CURRANLEO � P (�ERADDRESS ���� _ � TEL| -- FAX TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIALQ PRINT CLEARLY NBW:D RENOVATION:0 REPLACEMENT: J PLANS SUBMITTED: YES D NOD, FIXTURES-1 FLOOR— | oGm 1 2 3 4 S 0 7 U 8 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED WATER RECYCLE SYSTEM ................. DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER z" FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK ROOF DRAIN 7M 71., SHOWER STALL SERVICE MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING [-71 r-- JF_ U . _ _ .","-". """, I ­­'JIL 'I­ ­ . ­".. 11 INSURANCE COVERAGE: |have ucurrent|iabUbvinoumnue policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE8[Tj NO LJ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY F3 BOND [—N 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 —1 AGENT SIGNATURE OF OWNER ORAGENT —' I hereby certify that all of the details and information I have submitted or entered regarding this applicationt - uga and that all plumbing work and installations performed under m m o»enni�ivvuou ,miooppouanonwmuom m Maosauhuu��e��pmmmnoCode and noa�e,1*umm000ne�|Laws. ~� � � -' �~� PLUMBER'S NAME STEpHENVV|NSL0VV LICENSE 122O8 SIGNATURE MP�� JP -- C0RPORAT0N[�|#�3281C PARTNERSH|P| �# �LLC j#F � �-- -- '- ` ' - ^—� -----_ -�^ - / |_--_— - . COMPANY NAME E.F.VNNSLOVV PLUMBING&HEATING -ADDRESS 8REARD0NCIRCLE CITY|S0UTHYARM0UTH l3TATE Z|P -------'------- - l _ | [ �* � ^»zUh4_ TEL 508`394'7778 FAX i|SU8'304'82S8 CELL N/A EMAIL /NSPECT0NS��EFVV|N8LOVV.COM l�— ---- ` ----- -- ! The Commonwealth of Massachusetts - Department oflndustrialAccidents 9 (3 Office of Investigations (' Lafayette City Center �� 2 Avenue de Lafayette, Boston, MA 02111-1750 .„,.. i' 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, 11.0 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 " 1 e the ins and penalties of perjury that the information provided above is true and correct. 1' .--�1 Date: 01/02/2020 Signature: 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): 1.12Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.0Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • = CITY YARMOUTH MA DATE 05/26/20 PERMIT# PL-l-)/)- -oo �'0• S - ti JOBSITE ADDRESS'38 CAPTAIN SMALL ROAD OWNER'S NAME CURRAN, LEO GOWNER ADDRESS SOUTH YARMOUTH ...._ _ _ _ TELC 774-268-1548 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRIM CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z 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 525613$40.00 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES i NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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 I a YPP rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 71 ' !/ PLUMBER-GASFITTER NAME'STEPHEN WINSLOW LICENSE# 12298 ' SIGNATURE MP i MGF JP JGF LPG' CORPORATION # 3281C PARTNERSHIP # LLC # COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS!8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 1TEL 508-394 7778 FAX 508 394-8256 CELL, N/A . ............ ;EMAIL, INSPECTIONS@EFWINSLOW.COM Z-/U i7 The Commonwealth of Massachusetts Department of Industrial Accidents 9fOffice of Investigations �' Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 ftk k_"M twww 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): 1.111 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.ElWe are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ 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 • i the ins and penalties of perjury that the information provided above is true and correct. ' / 01/02/2020 Signature: Y h .4.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(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