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HomeMy WebLinkAboutBLDP&G-20-000484 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CI. '`"N4 CITY/TOWN WEST YARMOUTH MA DATE 7/22/2019 PERMIT#, P'*!O—EVO 7'l �y JOBSITE ADDRESS 50 CHERRY LANE-WEST YARMOUTH OWNERS NAME JOHN CURRY OWNER ADDRESS SAME TEL 508-760-3208 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:® PLANS SUBMITTED:YES 0 NO) 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 X 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' NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2' OTHER TYPE OF INDEMNITY 0 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 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 lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /JA PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MP E JP 0 CORPORATION g# 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 accountspavableeefwinslow.com p f� The Commonwealth of Massachusetts f , _ Department of Industrial Accidents �� l e 1 Congress Street, Suite•., sso imam 100 "` Boston,"" MA 02114-2017 mit www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, A licant Information Name (Business/Organization/Individual): E.F. WINSLOW PLUMBING & HEATING CO. IN Please Print Le ibl C Address: 8 REARDON CIRCLE City/State/Zip: SOUTH YARMOUTH, MA 02664 Phone #..508-394-7778 Are you an employer? Check the appropriate box: I am a employer with 88 Type of project (required): 1. ❑ employees (full and/or part-time).* 7. con 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ NEW deli T'l1CtlOn any capacity. [No workers' comp. insurance required.] ❑ Remoling 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] 9• ❑ Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 ❑ Building addition ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. l LEI Electrical repairs or additions 5.❑ 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 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entitiesh such. employees. If the sub-contractors have employees, they must provide their workers' comp. policy number. have I am an employer that is providing workers'compensation insurance for my employees. Below is the policyan information. and job site Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy # or Self-ins. Lic. #: 1909A 01f01/2020 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 bya fine ) and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and fine of up $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations p coverage verification. g of the DIA for insurance I do hereby certif, and a pal s nd pen hies of perjury that the information provided above is true and correct. Signature: 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbin In 6i. Other g spector Contact Person: Phone #: 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • _ WEST YARMOUTH '' n =j41;L—>' CITY MA DATE 7/99/19 PERMITrv�-+I�442Va2ygf JOBSITE ADDRESS 50 CHERRY LANE-WEST YARMOUTH OWNER'S NAME JOHN CURRY GOWNER ADDRESS SAME TEL 508-760-3208 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED:YES 0 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 I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER X OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Vg NO❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [vJ OTHER TYPE 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 tr 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 com nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 1229 SIGNATURE MP Ef MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION Ei# 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 )—_ The Commonwealth of Massachusetts ' Department of Industrial Accidents 1 Congress Street, 100 ?"' -- Boston, MA 02114-2017 SV lir WWJU.fytass.gov/dia \Yorkers' Compensation insurance Affidavit: I3uilders/Contractors/Electricia TO BE FILED WITH THE PERMITTING AUTHORITY. ns/Plumbers. A )licant Information Name (Business/Organization/Individual): E.F. WINSLOW PLUMBING & HEATING CO IN Please Print Le ibly Address: 8 REARDON CIRCLE City/State/Zip: SOUTH YARMOUTH, MA 02664 Phone #; 508-394-7778 Are you an employer? Check the appropriate box: I. i am a employer with 8$ "Type of project (required): _ ....._ employees (full and/or part-time).* 2.0 i am a sole proprietor or partnership and have no employees working for me in 7. New Jelin UCtioil any capacity. [No workers' comp. insurance required.] $ [] RemOling ❑I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 9. ❑ Demolition 4.0 i am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers' compensation insurance or are sole 1 1•❑ Electrical repairs or additions proprietors with no employees. 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.: 1 .0Roof repairs 6•0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14• El 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entt yes h tiesh such. employees. If the sub-contractors have employees, they must provide their workers' comp. policy number. ay I am an employer that is providing workers' compensation insurance for my employees. Below is the policyand information. job site Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy # or Self.-ins. Lic. #: 1909A 01/01/2020 Expiration Date: — Job Site Address: ate/Zip: Attach a copy of the workers' compensation policy declaration page (showin 1gpolicy thet number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable b a fine to Sl 500.0 and/or one-year imprisonme„t, as well as civil penalties in the form of a STOP WORK ORDER and y up U a fine of up to S250.()0 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 e pat s nd pen Ities of perjury that the information provided above is true and correct. Signature: ..„., Date: Phone #: 508-394-7778 — Official use only. Do not write in this area, to be completed by city or town official. City or 'I'©wn: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector spector Contact Person: Phone #: