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Home My WebLink AboutBLDP&G-20-003817 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY/rowN WEST YARMOUTH MA DATE 12/30/2019 PERMIT# P 19'V gg'7 JOBSITE ADDRESS 50 CHERRY LANE OWNER'S NAME JOHN CURRY OWNER ADDRESS SAME TEL 508.760.3208 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL 11 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[7 PLANS SUBMITTED:YES❑ NO I ' FIXTURES 1 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/OIUSAND 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 E NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY 121 OTHER TYPE OF INDEMNITY 0 BOND 0 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 t?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 co iance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' i / p i ` lead PLUMBERS NAME STEPHEN A.WINSLOW LICENSE# 12298 .l ' SIGNATURE MP g JP 0 CORPORATION 12# 3281C PARTNERSHIP 0# 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 accountspayableWefwinslow.com WORK ORDER#517729/PERMIT FEE-$40.00 4# The Commonwealth of Massachusetts 1.......' ;=( 1?ep�ct t»tent of industrial ceide,itts �a�i.. "lrr - .�.. ,.rnw d I Congress Street, Suite 100 - ,- Boston, MA 021.14-20/ 7 +fir *` ivww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITI1 THE PERMITTING AUTHORITY. Applicant Information Please Print LeEibly Name (Business,rOrganizationilndividttal): 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: Type of project (required): I 1.0 I am a employer with 88 .._._.._employees (full and/or part-time).* 7. ❑ New 20 I am a sole proprietor or partnership and have no employees working for nee in any capacity. [No Nvorkers' comp. insurance required.] 8. [] Remodeling 3.Li I am a homeowner doing all work myself. [No workers' comp. insurance required.] 0 Demolition 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 U Building addition ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees 1 1 .❑" Electrical repairs or additions 0 I am a general contractor and I have lured the sub-contractors listed on the attached sheet. l i._! Inmbin repairs or additions These sub-contractors have employees and have workers' comp. insurance.* 13. Roof repairs 6.E We are a corporation and its officers have exercised their right of exemption per MI, c. 14. El Other 152, *1(4). and we have no employees. [No workers' comp. insurance required.] *Any applicant that checks box ] must also fill out the section below showing their workers' compensation policy information. ' Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating suc Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have l} employees. If the sub-contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing rvorkers' compensation insurance for my employees. Belowispolicy information. I the and job site Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY 1909A 01/01/2020 Policy # or Self-ins. Lie. #: Expiration Date: 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. §25A1 � is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of upto S250.00 a day against the violator. A copyof this statement may be forwarded to the Office of Investigations of the DIA for insurance urance coverage verification. I do hereby certify and ze poi s nd pen Ities of perjury that the information provided above is true and corr ect. Signature: -,, ........I„...--- Date: Phone #: 508-394-7778 Official use only. Do not write iii this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing 6. Other brn�, Inspector Contact Person: Phone #: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY WEST YARMOUTH MA DATE 12/30/2019 PERMIT#N-0/215"238/7 JOBSITE ADDRESS 50 CHERRY LANE OWNER'S NAME JOHN CURRY GOWNER ADDRESS SAME TEL 508.760.3208 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL IA PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:g PLANS SUBMITTED:YES❑ NO Z 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES[Q 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 true a 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 complia with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MP[v7 MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION 0# 3281C 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 accountspayable@efwinslow.com WORK ORDER # 517729 / PERMIT FEE-$40.00 `� ;;LN,,,, .. The Commonwealth of Massachusetts r'u =i= t iiti . ..��. `; Accidents __ 1 congress Street, Suite 100 Boston, MA 02114-2017 � Department o.�.Industrial www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 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? Cheek the appropriate box: Type of project (required): 1.0✓ I am a employer with 88 employees (full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] ❑ Remodeling 3.❑I am a homeowner doing alI work myself. [No workers' comp, insurance required!.] r 9, ID Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. I !❑ Electrical repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12'❑plumbing repairs or additions These sub-contractors have employees and have workers' comp. insurance.+ 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. l •❑Other 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. * Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors 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 insurance for my employees. Below is the policyand job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY __ Policy # or Self-ins. Lic. #: 1909A 01I0112020 Expiration Date: 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 $1,500.00 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and le pat s nil pen hies of perjury that the information provided above is true and correct. Signature: -,--E Date: �,v d 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector b. Other Contact Person: Phone #: