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Home My WebLink AboutBLDP&G-20-005140 F . \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK C-. : '_. CITY YARMOUTH ' MA DATE 3-9-20 PERMIT# /� /°1�- Oick JOBSITE ADDRESS 56 MELVILLE ROAD,SOUTH YARMOUTH OWNER'S NAME COREY RUSSO P _ _ ..._..__..__.__-- OWNER ADDRESS SAME W j TEL 508-733-4102 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL El PRINT CLEARLY NEW:0 RENOVATION:11 � REPLACEMENT:El PLANS SUBMITTED: YES El NOE FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ! l CROSS CONNECTION DEVICEa nj DEDICATED SPECIAL WASTE SYSTEM 1--_--11----- ' I L DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM ' DEDICATED GRAY WATER SYSTEM , ; DEDICATED WATER RECYCLE SYSTEM L DISHWASHER DRINKING IIIIIFIIIIIIIIIIIrIIIIIIIIIIIIIMIIIWIIIIIIINIIIIIII FOOD DISPOSER ___— w... Milli. 111111". FLOOR/AREA DRAIN __ INTERCEPTOR(INTERIOR) ;,, KITCHEN SINK '" , LAVATORY I ROOF DRAIN ; ._ SHOWER STALL lall Ma 01.1111111111111111111111111 NI 11111111111. 1 SERVICE/MOP SINK l TOILET 3 7 URINAL r ._ W_ �� WASHING MACHINE CONNECTION --_7..� WATER HEATER ALL TYPES fix um mil am am am no es WATER PIPING i L OTHER ION aiiiM---Ml11nfp.EMmgilrMMIIIIMIMNIIIII ---PiMIF---1MMNinllNI INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Li NO LI IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY iv I OTHER TYPE OF INDEMNITY BOND U 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 El 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 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 li with II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME[STEPHEN WINSLOW j LICENSE# 12298 _ SIGNATURE MPLI JP ID CORPORATION#��I3281C PARTNERSHIPLj# wa ILLC0# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH 1 STATE MA ZIP 02664 - TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM i r/ The Commonwealth of Massachusetts a Department of Industrial Accidents 1a 2--- _ Office of Investigations 1ar.— ', Lafayette City Center rJ vzair 2Avenue de Lafayette, Boston,MA 02111-1750 .w —„..``'� 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. El 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]** II.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box 41 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 ' e the gtzins and penalties of perjury that the information provided above is true and correct. Signature: �'i -._AIL Date: 01/02/2020 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): I.❑Board of Health 2.0 Building Department 3.1=1 City/Town Clerk 4.❑Licensing Board 5,❑Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE13-9-20 'PERMIT# 0, '° 770 Ny • JOBSITE ADDRESS56 MELVILLE ROAD SOUTH YARMOUTH OWNER'S NAME COREY RUSSO GOWNER ADDRESS SAME TEL 508-733-4102 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL I RESIDENTIAL PRINT 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 x J_ OTHER 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 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 aPP rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. y PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP MGF JP JGF 1-1 LPGI CORPORATION # 3281CPARTNERSHIP #I LLC # COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY [SOUTH YARMOUTH STATE MA ZIP102664 TEL 508-394-7778 FAX,508-394-8256 1 CELL N/A �EMAIL1 INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents =' =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 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, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *My 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 " 7 the ins and penalties of perjury that the information provided above is true and correct. Signature: ?' " A Date: 01/02/2020 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.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: • www.mass.gov/dia